Risk Prediction With Procalcitonin and Clinical Rules in Community-Acquired Pneumonia

David T. Huang, Lisa A. Weissfeld, John A. Kellum, Donald M. Yealy, Lan Kong, Michael Martino, Derek C. Angus

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Abstract

Study objective: The Pneumonia Severity Index and CURB-65 predict outcomes in community-acquired pneumonia but have limitations. Procalcitonin, a biomarker of bacterial infection, may provide prognostic information in community-acquired pneumonia. Our objective is to describe the pattern of procalcitonin in community-acquired pneumonia and determine whether procalcitonin provides prognostic information beyond the Pneumonia Severity Index and CURB-65. Methods: We conducted a multicenter prospective cohort study in 28 community and teaching emergency departments. Patients presenting with a clinical and radiographic diagnosis of community-acquired pneumonia were enrolled. We stratified procalcitonin levels a priori into 4 tiers: I: less than 0.1; II: greater than 0.1 to less than 0.25; III: greater than 0.25 to less than 0.5; and IV: greater than 0.5 ng/mL. Primary outcome was 30-day mortality. Results: One thousand six hundred fifty-one patients formed the study cohort. Procalcitonin levels were broadly spread across tiers: 32.8% (I), 21.6% (II), 10.2% (III), and 35.4% (IV). Used alone, procalcitonin had modest test characteristics: specificity (35%), sensitivity (92%), positive likelihood ratio (1.41), and negative likelihood ratio (0.22). Adding procalcitonin to the Pneumonia Severity Index in all subjects minimally improved performance. Adding procalcitonin to low-risk Pneumonia Severity Index subjects (classes I to III) provided no additional information. However, subjects in procalcitonin tier I had low 30-day mortality, regardless of clinical risk, including those in higher risk classes (1.5% versus 1.6% for those in Pneumonia Severity Index classes I to III versus classes IV/V). Among high-risk Pneumonia Severity Index subjects (classes IV/V), one quarter (126/546) were in procalcitonin tier I, and the negative likelihood ratio of procalcitonin tier I was 0.09. Procalcitonin tier I was also associated with lower burden of other adverse outcomes. Similar results were observed with CURB-65 stratification. Conclusion: Selective use of procalcitonin as an adjunct to existing rules may offer additional prognostic information in high-risk patients.

Original languageEnglish (US)
Pages (from-to)48-58.e2
JournalAnnals of Emergency Medicine
Volume52
Issue number1
DOIs
StatePublished - Jul 2008

All Science Journal Classification (ASJC) codes

  • Emergency Medicine

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    Huang, D. T., Weissfeld, L. A., Kellum, J. A., Yealy, D. M., Kong, L., Martino, M., & Angus, D. C. (2008). Risk Prediction With Procalcitonin and Clinical Rules in Community-Acquired Pneumonia. Annals of Emergency Medicine, 52(1), 48-58.e2. https://doi.org/10.1016/j.annemergmed.2008.01.003