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Purpose: We aimed to determine whether serum procalcitonin (PCT) values could help in identifying flu in patient admitted to the emergency department (ED) with influenza-like illness (ILI) during influenza A(H1N1)2009 pandemic., Methods: An observational retrospective cohort study was performed in a referral ED for emerging infectious diseases. All patients tested for influenza A(H1N1)2009 by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) and procalcitonin between June 2009 and January 2010 were analyzed. PCT was studied for its negative predictive value of bacterial infection. Patients PCT-/RT-PCR + were considered as true positive., Results: On the 80 patients included, 16 were positive for influenza A(H1N1)2009 RT-PCR, all but one of them had low PCT concentrations. Conversely, 19 (30%) of the 64 patients with negative RT-PCR had elevated PCT concentrations. For a PCT threshold <0.25 μg/L, sensitivity was 0.94, specificity 0.30, positive predictive value 0.25 and negative predictive value 0.95 for the diagnosis of flu., Conclusion: In the context of an influenza pandemic, serum PCT measurement may be useful for clinical decisions in the ED as most of RT-PCR confirmed patients have low PCT values. Patients with PCT above 0.25 μg/L are unlikely to have a unique diagnosis of flu.

Background: Procalcitonin (PCT), an inflammatory blood biomarker, is well studied in infectious diseases. Its prognostic value in unselected emergency department (ED) patients remains yet undefined. Herein, we investigated association of admission PCT levels and mortality in a large, international-multicenter ED patient cohort., Methods: We prospectively enrolled 6970 unselected, consecutive, adult, medical patients seeking ED care in three tertiary-care hospitals in Switzerland, France and the USA. We used multivariable logistic regression models to examine association of admission PCT levels (as a continuous predictor and across cut-offs) and 30-day mortality. We also investigated subgroup effects by main diagnosis, comorbidities and clinical features at presentation., Results: During the 30-day follow-up, 328 (4.7%) participants died. Mortality increased stepwise within higher PCT cut-offs (0.05, 0.1, 0.25, 0.5 ng/mL) from 1%, 3%, 7%, 13% to 15%, respectively. This association was also confirmed in a fully-adjusted model including age, gender, main symptom, main diagnosis and vital parameters on admission. Receiver operating characteristic (ROC) curve analysis showed that PCT differentiated well between survivors and non-survivors in the overall cohort (area under ROC curve [AUC] 0.75) with best results for patient with metabolic (AUC: 0.85) and cardiovascular disease (AUC: 0.82). Addition of PCT also improved the prognostic accuracy of the quick sequential organ failure assessment (qSOFA) score from an AUC of from 0.61 to 0.76 (p<0.001). Results were similar for other secondary endpoints including intensive care unit (ICU) admission and hospital readmission., Conclusions: In this large and heterogenous medical ED patient cohort, admission PCT was a strong and independent outcome predictor for 30-day mortality across different medical diagnoses independent of underlying infection. PCT may help to improve risk stratification in unselected medical ED patients.

Background: Facial cellulitis is an infectious disease that may require emergency surgical drainage based on clinical assessment. To date, no biological marker has been reported to be useful for risk stratification. Procalcitonin (PCT) is a diagnostic and prognostic sepsis biomarker. We aimed to study the usefulness of PCT dosage for the risk-stratification of facial cellulitis., Patients and Methods: This was a monocentric prospective study conducted in a referral center for maxillofacial emergencies. Patients with a diagnosis of facial cellulitis were included and underwent a PCT measurement at admission. The main criterion was the requirement for surgical drainage., Results: Seventy consecutive patients were included in a 7-months period, mean age 35 ± 14 years. Surgical drainage was required for 48 patients (68%). Serum PCT concentrations were strictly negative in most patients (median [IQR]: 0.05 μg/L [0.05; 0.10]). Only 6 patients (9%) had PCT values above the clinical threshold of 0.25 μg/L. At a threshold of 0.1 μg/L, PCT was 30% sensitive and 100% specific for surgical drainage requirement., Conclusion: PCT level usually remains in a low range in facial cellulitis and seems to have a limited added value for risk stratification., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Procalcitonin (PCT) is increasingly being used for the diagnostic and prognostic work up of patients with suspected infections in the emergency department (ED). Recently, B·R·A·H·M·S PCT direct, the first high sensitive point-of-care test (POCT), has been developed for fast PCT measurement on capillary or venous blood samples., Methods: This is a prospective, international comparison study conducted in three European EDs. Consecutive patients with suspicion of bacterial infection were included. Duplicate determination of PCT was performed in capillary (fingertip) and venous whole blood (EDTA), and compared to the reference method. The diagnostic accuracy was evaluated by correlation and concordance analyses., Results: Three hundred and three patients were included over a 6-month period (60.4% male, median age 65.2 years). The correlation between capillary or venous whole blood and the reference method was excellent: r2=0.96 and 0.97, sensitivity 88.1% and 93.0%, specificity 96.5% and 96.8%, concordance 93% and 95%, respectively at a 0.25 μg/L threshold. No significant bias was observed (-0.04 and -0.02 for capillary and venous whole blood) although there were 6.8% and 5.1% outliers, respectively. B·R·A·H·M·S PCT direct had a shorter time to result as compared to the reference method (25 vs. 144 min, difference 119 min, 95% CI 110-134 min, p<0.0001)., Conclusions: This study found a high diagnostic accuracy and a faster time to result of B·R·A·H·M·S PCT direct in the ED setting, allowing shortening time to therapy and a more wide-spread use of PCT.

Introduction: Community-acquired pneumonia (CAP) requires prompt treatment, but its diagnosis is complex. Improvement of bacterial CAP diagnosis by biomarkers has been evaluated using chest X-ray infiltrate as the CAP gold standard, producing conflicting results. We analyzed the diagnostic accuracy of biomarkers in suspected CAP adults visiting emergency departments for whom CAP diagnosis was established by an adjudication committee which founded its judgment on a systematic multidetector thoracic CT scan., Methods: In an ancillary study of a multi-center prospective study evaluating the impact of systematic thoracic CT scan on CAP diagnosis, sensitivity and specificity of C-reactive protein (CRP) and procalcitonin (PCT) were evaluated. Systematic nasopharyngeal multiplex respiratory virus PCR was performed at inclusion. An adjudication committee classified CAP diagnostic probability on a 4-level Likert scale, based on all available data., Results: Two hundred patients with suspected CAP were analyzed. The adjudication committee classified 98 patients (49.0 %) as definite CAP, 8 (4.0 %) as probable, 23 (11.5 %) as possible and excluded in 71 (35.5 %, including 29 patients with pulmonary infiltrates on chest X-ray). Among patients with radiological pulmonary infiltrate, 23 % were finally classified as excluded. Viruses were identified by PCR in 29 % of patients classified as definite. Area under the curve was 0.787 [95 % confidence interval (95 % CI), 0.717 to 0.857] for CRP and 0.655 (95 % CI, 0.570 to 0.739) for PCT to detect definite CAP. CRP threshold at 50 mg/L resulted in a positive predictive value of 0.76 and a negative predictive value of 0.75. No PCT cut-off resulted in satisfactory positive or negative predictive values. CRP and PCT accuracy was not improved by exclusion of the 25 (25.5 %) definite viral CAP cases., Conclusions: For patients with suspected CAP visiting emergency departments, diagnostic accuracy of CRP and PCT are insufficient to confirm the CAP diagnosis established using a gold standard that includes thoracic CT scan. Diagnostic accuracy of these biomarkers is also insufficient to distinguish bacterial CAP from viral CAP., Trial Registration: ClinicalTrials.gov registry NCT01574066 (February 7, 2012).

Distinction between infection and febrile disease flare in patients with systemic lupus erythematosus (SLE) is fundamental but often difficult to make, because clinical presentation can be similar. A systematic review of all articles indexed in PubMed through October 2013 was performed, in order to examine the potential role of procalcitonin (PCT) for the discrimination between SLE flare and infection. Among the 12 papers identified, 5 articles reported on PCT levels in SLE patients without infection, 6 compared PCT levels between SLE patients with flare versus those with infection, and 1 analyzed PCT levels in active patients with and without bacterial infection. These data suggest the absence of correlation between PCT levels and SLE disease activity. Furthermore, PCT levels detected during disease flares are lower than those observed during bacterial infections. PCT can therefore be used accurately in the early differentiation between bacterial infection and flare in febrile SLE patients. Raised PCT levels ≥0.5 μg/L should strongly suggest bacterial infection in the context of SLE, keeping in mind the limited data available in case of hemophagocytic syndrome. Elevated PCT levels in SLE patients should always prompt a thorough search for sources of potential infection.

The emergency unit is one of the main places for acute medical care and therefore, has a pivotal role in determining a diagnosis of bacterial infection and initiating antibiotic therapy. There is an unquestionable and growing interest for infection biomarkers because of the polymorphism of septic state presentations in the emergency unit and the lack of accuracy of available biological tools. The C Reactive protein (CRP) is a biomarker of inflammation, not of infection. CRP is highly sensitive but lacks specificity. Moreover, there are few interventional studies evaluating its true added diagnostic value in the emergency unit, therefore preventing using CRP as a biomarker of infection. Serum procalcitonin (PCT) dosage is more specific for the diagnosis of bacterial infection. PCT levels do not increase or only slightly in non-bacterial inflammatory syndromes. PCT also provides prognostic information and risk stratification assessment in the emergency unit. Moreover, many authors of interventional studies have validated the contribution of PCT in decision taking for antibiotic therapy when suspecting low respiratory tract infection. It is currently the first-line biomarker of infection in the emergency unit. Other biomarkers such as presepsin (sCD14) may be contributive for the diagnosis and prognosis., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 μg/L and +31 % if PCT > 0.25 μg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 μg/L and +13 % if PCT > 0.25 μg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 μg/L and +19 % if PCT > 0.25 μg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.

Objective: To study the contribution of lactate and procalcitonin (PCT) serum measurements for the diagnosis and the risk-stratification of patients with suspected infection presenting to the ED., Methods: Single-center one year observational study on 462 consecutive patients. Multivariate analysis to assess variables associated with sepsis, severe sepsis, septic shock and severe outcome., Results: Multivariate analysis (Odds ratio [95% CI]), showed that PCT was the best independent variable to identify sepsis (3.98 [2.60-6.10]), while lactate was the best to diagnose severe sepsis (10.88 [6.51-18.19]). Patients with both lactate above 2 mmol·L(-1) and PCT above 0.8 ng·mL(-1) had an enhanced risk of severe outcome., Conclusions: the dosages of lactate and PCT are complementary for the diagnosis and risk-stratification of patients evaluated in the ED for suspected infection.

Background: In controlled studies, procalcitonin (PCT) has safely and effectively reduced antibiotic drug use for lower respiratory tract infections (LRTIs). However, controlled trial data may not reflect real life., Methods: We performed an observational quality surveillance in 14 centers in Switzerland, France, and the United States. Consecutive adults with LRTI presenting to emergency departments or outpatient offices were enrolled and registered on a website, which provided a previously published PCT algorithm for antibiotic guidance. The primary end point was duration of antibiotic therapy within 30 days., Results: Of 1759 patients, 86.4% had a final diagnosis of LRTI (community-acquired pneumonia, 53.7%; acute exacerbation of chronic obstructive pulmonary disease, 17.1%; and bronchitis, 14.4%). Algorithm compliance overall was 68.2%, with differences between diagnoses (bronchitis, 81.0%; AECOPD, 70.1%; and community-acquired pneumonia, 63.7%; P < .001), outpatients (86.1%) and inpatients (65.9%) (P < .001), algorithm-experienced (82.5%) and algorithm-naive (60.1%) centers (P < .001), and countries (Switzerland, 75.8%; France, 73.5%; and the United States, 33.5%; P < .001). After multivariate adjustment, antibiotic therapy duration was significantly shorter if the PCT algorithm was followed compared with when it was overruled (5.9 vs 7.4 days; difference, -1.51 days; 95% CI, -2.04 to -0.98; P < .001). No increase was noted in the risk of the combined adverse outcome end point within 30 days of follow-up when the PCT algorithm was followed regarding withholding antibiotics on hospital admission (adjusted odds ratio, 0.83; 95% CI, 0.44 to 1.55; P = .56) and regarding early cessation of antibiotics (adjusted odds ratio, 0.61; 95% CI, 0.36 to 1.04; P = .07)., Conclusions: This study validates previous results from controlled trials in real-life conditions and demonstrates that following a PCT algorithm effectively reduces antibiotic use without increasing the risk of complications. Preexisting differences in antibiotic prescribing affect compliance with antibiotic stewardship efforts., Trial Registration: isrctn.org Identifier: ISRCTN40854211.

Whereas C-reactive protein (CRP), procalcitonin (PCT) and mid-regional pro-atrial natriuretic peptide (ANP) may be of use at the bedside in the management of adult patients with infectious disorders, their usefulness has not been established in the setting of acute pyelonephritis. To assess the effectiveness of CRP, PCT and ANP measurements in guiding emergency physicians' decisions whether to admit to hospital patients with acute pyelonephritis, we conducted a multicentre, prospective, observational study in 12 emergency departments in France; 582 consecutive patients were included. The reference standard for admission was defined by experts' advice combined with necessity of admission or death during the 28-day follow-up. Baseline CRP, PCT and ANP were measured and their accuracy in identifying the necessity of admission was analysed using area under curves (AUC) of receiver-operating characteristic (ROC) plots. According to the reference standard, 126 (22%) patients required admission. ANP (AUC 0.75, 95% CI 0.69-0.80) and PCT (AUC 0.75, 95% CI 0.71-0.80) more accurately predicted this than did CRP (AUC 0.69, 95% CI 0.64-0.74). The positive and negative likelihood ratios for each biomarker remained clinically irrelevant whatever the threshold. Our results did not support the use of these markers to help physicians in deciding about admission of patients experiencing acute pyelonephritis in daily practice.

Background: The use at bedside of C-reactive protein (CRP), procalcitonin (PCT) or mid-regional pro-atrial natriuretic peptide (ANP) has been advocated to help management of patients with community-acquired pneumonia (CAP) in emergency medicine., Objective: To assess the effectiveness of CRP, PCT, and ANP measures in assisting emergency physicians deciding hospital admission for CAP with low risk of complication., Design: Multicenter, prospective, observational study with blind evaluation., Setting: Emergency departments of 12 French hospitals., Patients: Five hundred forty-nine consecutive, immunocompetent adult patients with mild CAP., Measurements: Centralized and blind measure of baseline CRP, PCT, and ANP; sensitivity, specificity, and positive and negative likelihood ratios for determining hospital admission. Gold standard for admission was defined by experts' advice combined with admission requirement or death at 28 days. Optimal threshold values were determined by receiver operating characteristic (ROC) curves, and area under curve (AUC) of the three biomarkers was compared., Results: According to gold standard, 310 (56%) patients required admission and 239 (44%) needed to be discharged. PCT and ANP levels increased with Pneumonia Severity Index risk categories. ANP (AUC 0.76 [95% CI 0.72-0.80]) more accurately predicted admission requirement than did PCT (AUC 0.65 [95% CI 0.61-0.70]) or CRP (AUC 0.59 [95% CI 0.54-0.64]) (both p values <0.01). We determined that 135 pmol/L was a threshold for ANP level to discriminate admission requirement (positive likelihood ratio 7.45 [95% CI 4.22-8.16])., Conclusions: In a selected population of CAP with low risk of complication, a single ANP measurement was more accurate than CRP and PCT to predict appropriate admission. These results should be confirmed by additional studies.

Background: Accurate identification of bacterial infections in patients presenting at the emergency department is crucial for early and rational antibiotic treatment. In this situation, using a cut-off of 0.25 microg/L for procalcitonin allows for carefully monitoring of febrile patients. Most previous studies have been performed with the reference B.R.A.H.M.S PCT KRYPTOR assay. The goal of this study was to compare this test with the VIDAS B.R.A.H.M.S PCT((R)) assay and to validate clinically relevant cut-off thresholds., Methods: This prospective study was conducted in adults presenting to the emergency departments of a tertiary hospital. We included 305 consecutive patients that had procalcitonin requested. Procalcitonin was measured first with the KRYPTOR, then with the VIDAS systems. Statistical analysis consisted in Passing and Bablok and Bland-Altman plots., Results: In the overall cohort, 176 patients had procalcitonin concentrations measured using both methods and were well correlated. The Bland-Altman plot exhibited a bias of 0.108 [95% confidence interval: -0.044 to 0.260]. The concordance at different procalcitonin cut-off thresholds, respectively of 0.1, 0.25, 0.5 and 2 microg/L, indicated that above 0.25 microg/L, the kappa coefficient was >0.80., Conclusions: A highly significant correlation was observed between the two automated assays. Procalcitonin concentrations obtained from both methods led to the same clinical interpretation.

When fever occurs in a patient treated with a neuroleptic, the diagnosis of a neuroleptic malignant syndrome is difficult to differentiate to that of an infectious event. Among inflammation biomarkers of inflammation, serum procalcitonin levels increase both quickly and specifically during a bacterial infection. We report the first case of a neuroleptic malignant syndrome associated with a significant increase of serum procalcitonin levels, without concomitant septic syndrome. The neuroleptic malignant syndrome might be a non-infectious clinical situation associated with an increased serum procalcitonin concentration.

Objective: To study the effect of non-exertional heatstroke on serum procalcitonin (PCT) levels., Design: Cohort study., Setting: The emergency and intensive care departments of two academic tertiary-care hospitals, Paris, France, Patients: A total of 53 patients with defined heatstroke attending the emergency department and/or the intensive care unit during the August 2003 heat wave in France., Interventions: None., Measurements: Serum PCT measurement using a sensitive assay and vital and routine biological variables on arrival of patients presenting with classic heatstroke. Thirty-day mortality was recorded., Results: Among the 53 patients included, 14 (26%) were admitted to an intensive care unit (ICU). At 30 days, 24 patients (45%) had died. Median PCT value was 0.58 microg/l (95% confidence interval 0.16-1.61) and 31 (58%) patients had PCT above 0.2 microg/l (PCT+). Temperature above or equal to 40 degrees C was the only variable significantly associated with fatal outcome. Median PCT values were 1.4 microg/l (0.16-4.71) and 0.18 microg/l (0.12-1.61) in the group of deceased and surviving patients respectively (p = 0.22). All patients admitted in ICU had elevated PCT values. Patients PCT+ initially presented with a more pronounced systemic inflammatory response. Microbiologically or clinically documented infection was not more frequent in PCT+ group., Conclusion: High serum PCT levels can be observed in heatstroke without any concomitant documented bacterial infection. The PCT is not a valid mortality predictor in heatstroke but could be an indicator of the severity of illness. Heatstroke could represent a model of a "non-septic" pathway of PCT synthesis.

Objective: Procalcitonin has been advocated as a specific biomarker for bacterial infection. We performed this study to determine whether accuracy of procalcitonin for diagnosis of postoperative bacterial infection is affected by renal function after aortic surgery., Design: Single-center prospective study., Setting: University hospital., Patients: Two hundred seventy-six patients scheduled for elective major aortic surgery., Interventions: Blood samples were taken before surgery and each day over the 5-day postoperative period, and measurement of serum procalcitonin was performed. Diagnosis of infection was performed by a blinded expert panel. Renal function was assessed using an estimate of creatinine clearance with the Cockcroft formulas. Renal dysfunction was defined as a creatinine clearance <50 mL x min(-1)., Measurements and Main Results: Infection was diagnosed in 67 patients. Seventy five patients (27%) had postoperative renal dysfunction. Procalcitonin was significantly higher in infected patients, with a peak reached at the fourth postoperative day, but it was significantly higher in patients with impaired renal function in both control and infected patients. The optimal threshold of procalcitonin markedly differed in patients with renal dysfunction compared with patients without renal dysfunction (2.57 vs. 0.80 ng x mL(-1), p < .05). The diagnostic accuracy of procalcitonin significantly increased (0.74 vs. 0.70, p < .05) when the threshold of procalcitonin was adapted to the renal function. The elevation of procalcitonin occurred 2 days before the medical team was able to diagnose infection., Conclusions: Procalcitonin is a valuable marker of bacterial infections after major aortic surgery, but renal function is a major determinant of procalcitonin levels and thus different thresholds should be applied according to renal function impairment.

Background: Cardiopulmonary bypass induces a nonspecific inflammatory response. Procalcitonin has been advocated as a specific biomarker for infection. The authors studied the accuracy of procalcitonin to diagnose postoperative infection after cardiac surgery and compared it with those of C-reactive protein, white blood cell count, and interleukins 6 and 8., Methods: The authors prospectively included 100 patients scheduled to undergo elective cardiac procedures with cardiopulmonary bypass. Blood samples were taken before surgery and each day over the 7-day postoperative period, and measurement of procalcitonin, C-reactive protein, white blood cell count, and interleukins 6 and 8 were performed. Diagnosis of infection was performed by a blinded expert panel. Data are expressed as value [95% confidence interval]., Results: Infection was diagnosed in 16 patients. Procalcitonin was significantly higher in infected patients, with a peak reached on the third postoperative day. Only the areas under the receiver operating curve of procalcitonin (0.88 [0.71-0.95]) and C-reactive protein (0.72 [0.58-0.82]) were significantly different from the no-discrimination curve, and that of procalcitonin was significantly different from those of C-reactive protein, white blood cell count, and interleukins 6 and 8. A procalcitonin value greater than 1.5 ng/ml beyond the second day diagnosed postoperative infection with a sensitivity of 0.93 [0.70-0.99] and a specificity of 0.80 [0.70-0.87]. Procalcitonin was significantly higher in patients who died (27.5 [1.65-40.5] vs. 1.2 [0.7-1.5] ng/ml; P < 0.001)., Conclusion: Procalcitonin is a valuable marker of bacterial infections after cardiac surgery.

Purpose: The availability of a sensitive, specific and prognostic marker of bacterial infection is a major issue. More than ten years after the first publication assessing the usefulness of serum procalcitonin dosage (PCT), its exact place in the diagnostic process remained to be defined. The purpose of this review is to point out the indications of PCT measurement in clinical practice in the adult population., Relevant Data: PCT is an early, sensitive but above all specific marker of severe bacterial/parasitic infections. After being studied mostly in critically ill patients, the indications of PCT measurement have been extended to medical and emergency medicine practice, generating cut-off points between 0.2 and 0.6 microg/L. The medical area of application of PCT measurement is varied: discrimination between inflammatory disease and infectious complication or between bacterial/parasitic and viral infection, diagnosis of negative result gram staining meningitis or shock, assessment of antibiotic treatment efficiency. Moreover, PCT measurement provides outcome information in that sepsis-related raised PCT levels seem to be closely related to the magnitude of host systemic inflammatory response to microbial invasion. High PCT levels allow the early identification of patients prone to develop severe sepsis or septic shock., Prospects: After the first published study reporting the usefulness of PCT as a screening biological tool in emergency medicine, future studies will probably refined the place of PCT in such practice fields: decision about inpatient or outpatient management or antibiotics dispensation. Finally, PCT measurement could help physician in screening which septic patients should benefit from sepsis innovative therapeutics.

Introduction: Identification of bacterial infections is crucial if treatment is to be initiated early and antibiotics used rationally. The primary objective of this study was to test the efficiency of procalcitonin (PCT) in identifying bacterial/parasitic episodes among febrile adult patients presenting to an emergency department. Secondary objectives were to identify clinical or biological variables associated with either bacterial/parasitic infection or critical illness., Methods: This was a prospective, single centre, non-interventional study, conducted in the adult emergency department of an academic tertiary care hospital. We included patients with body temperature of 38.5 degrees C or greater. A serum sample for measurement of PCT was collected in the emergency room. Patients were followed up until day 30. After reviewing the medical files, two independent experts, who were blind to the PCT results, classified each of the patients as having a bacterial/parasitic infection, viral infection, or another diagnosis., Results: Among 243 patients included in the study, 167 had bacterial/parasitic infections, 35 had viral infections and 41 had other diagnoses. The PCT assay, with a 0.2 microg/l cutoff value, had a sensitivity of 0.77 and a specificity of 0.59 in diagnosing bacterial/parasitic infection. Of the patients with PCT 5 microg/l or greater, 51% had critical illness (death or intensive care unit admission) as compared with 13% of patients with lower PCT values., Conclusion: Bearing in mind the limitations of an observational study design, the judgements of the emergency department physicians were reasonably accurate in determining the pretest probability of bacterial/parasitic infection. PCT may provide additional, valuable information on the aetiology and prognosis of infection in the emergency department.

We prospectively evaluated serum procalcitonin concentrations in patients who presented to an emergency department (ED) with suspected infectious or inflammatory disease. Of 195 study patients, 68 had final diagnosis of systemic infection, and 24 of those 68 had elevated serum procalcitonin levels (>0.5 ng/mL). The procalcitonin level had a sensitivity of 0.35 and specificity of 0.99 for the diagnosis of systemic infection. In multivariate analysis, the procalcitonin level was the only independent variable associated with this diagnosis; in contrast, the C-reactive protein level was not. All patients with systemic infections who ultimately died had procalcitonin levels of >0.5 ng/mL at admission. Procalcitonin levels were significantly higher in patients who ultimately died of systemic infection than in patients who survived. The optimal procalcitonin threshold for the ED population may be lower than that proposed for critically ill patients. Determination of the procalcitonin level may be useful for screening and prognosis of more-severely ill ED patients.

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Abstract: Purpose: The availability of a sensitive, specific and prognostic marker of bacterial infection is a major issue. More than ten years after the first publication assessing the usefulness of serum procalcitonin dosage (PCT), its exact place in the diagnostic process remained to be defined. The purpose of this review is to point out the indications of PCT measurement in clinical practice in the adult population. Relevant data: PCT is an early, sensitive but above all specific marker of severe bacterial/parasitic infections. After being studied mostly in critically ill patients, the indications of PCT measurement have been extended to medical and emergency medicine practice, generating cut-off points between 0.2 and 0.6 μg/L. The medical area of application of PCT measurement is varied: discrimination between inflammatory disease and infectious complication or between bacterial/parasitic and viral infection, diagnosis of negative result gram staining meningitis or shock, assessment of antibiotic treatment efficiency. Moreover, PCT measurement provides outcome information in that sepsis-related raised PCT levels seem to be closely related to the magnitude of host systemic inflammatory response to microbial invasion. High PCT levels allow the early identification of patients prone to develop severe sepsis or septic shock. Prospects: After the first published study reporting the usefulness of PCT as a screening biological tool in emergency medicine, future studies will probably refined the place of PCT in such practice fields: decision about inpatient or outpatient management or antibiotics dispensation. Finally, PCT measurement could help physician in screening which septic patients should benefit from sepsis innovative therapeutics. [Copyright &y& Elsevier]