Transcript Serum procalcitonin and C-reactive protein in children with

Serum procalcitonin and C-reactive
protein in children with communityacquired pneumonia
K.Gogvadze, I.Guramishvili, I.Chkhaidze,
K.Nemsadze, T.Maglakelidze
M.Guramishvili Pediatric Clinic,
State Medical University,
I.Javakhishvili Diagnostic Centre,
Tbilisi, Georgia
BACKGROUND
Community acquired pneumonia
is a common clinical childhood
problem. Bacterial pneumonia
cannot be differentiated from
viral or atypical pneumonia only
on
the
basis
of
patient
characteristics.
BACKGROUND (cont.)
The routine laboratory tests and
chest
x-ray
examination
discriminate
poorly
between
bacterial, viral or atypical causes of
pneumonia in children. As a result,
most children with pneumonia are
treated with antibiotics without
knowledge of the causative agent.
BACKGROUND (cont.)
The identification of markers of
infection for differentiation of
causes of pneumonia would be
of great value for guiding
treatment decisions and followup.
BACKGROUND (cont.)
C reactive protein is a protein of the acute
phase, its production is stimulated mainly
by interleukin 6, interleukin 1, and tumour
necrosis factor in response to infection
or tissue inflammation. However, even
though values of C reactive protein may
reflect the severity of inflammation, its
role in differentiating bacterial from viral
infections is not definitely proved.
BACKGROUND (cont.)
The
usefulness
of
procalcitonin
concentration
in
diagnosis,
and
particularly the differential diagnosis of
several infectious diseases, is still the
matter of some controversy, although it
has become generally accepted that PCT
is a useful marker for severe bacterial
infections such are sepsis or meningitis.
The Aim
The aim of the present study was to
investigate PCT and CRP value in
children with CAP to examine
whether PCT and CRP could be used
to distinguish viral, bacterial and
atypical pneumonia in children.
Selection criteria
We included only those children who
were immunocompetent, who had
no chronic disease, pulmonary or
otherwise, and who had not received
antibiotics in the 10 days before
admission.
Patients and Methods
This was an open, prospective,
observational study of 36 pediatric
patients with pneumonia admitted to
the M.Guramishvili Pediatric Clinic,
Tbilisi, Georgia from September
2004 to January 2006.
Patients and Methods (cont)
The diagnosis of bacterial and atypical
pneumonia was based on high single
values and a significant rise in antibody
titers between acute and convalescent
sera. The diagnosis of viral pneumonia
was based on virus antigen detection in
nasopharyngeal aspirate and significant
rise in antibody titers between acute and
convalescent sera.
Patients and Methods (cont)
The
following
agents
had
been
investigated:
• virus: RSV, Adenovirus, Influenza A,
parainfluenza;
• bacteria: Streptococcus pneumoniae,
Moraxella
cattarhalis,
Haemophilus
influenza, Staphylococcus aureus;
• atypical
pathogens:
Chlamydia
pneumonia, Mycoplasma pneumonia,
Legionella.
Patients and Methods (cont)
C-reactive protein was analyzed
using an enzymimunoassay method
(CRP ELISA, IBL Hamburg, Germany).
Procalcitonin was measured by
immunoluminometric assay (ILMA)
(Brahms
Diagnostica,
Berlin,
Germany).
Diagnostic criteria
The diagnosis of pneumonia was
based on a simultaneous finding of an
infiltrate on the chest radiograph and
fever (>37.5°C) and/or respiratory
symptoms. The radiological diagnosis
was made by two independent
pediatric radiologists.
Flow chart of the study
Presumed pneumonia
n=45
Radiologically
confirmed pneumonia
n=36
Viral
Pneumonia
n=12
(33%)
Bacterial
Pneumonia
n=11
(30%)
Atypical
Pneumonia
n=5
(14%)
Etiology
Unknown
n=8
(22%)
Etiology of CAP
Etıology unknown
22%
Etıology known
78%
Results: Etiology
Of the 36 patients studied, 2 (mean age
2.8 years; range 0.8–6 years) had blood
cultures positive for bacterial pathogen
and 9 (mean age 3.9 years; range 0.5–12
years)
had
bacterial
pneumonia
diagnosed
on
the
basis
of
seroconversion (9 - S.pneumonia, 2 –
Haemophilus influenza).
Results: Etiology (cont.)
Of the 36 patients studied, 12 (mean
age 2.2 years; range 0.3–3.8 years)
had viral pneumonia diagnosed on
the basis of single IgM titre or fourfold increase of IgG titre in paired
sera (5 - Adenovirus, 4 - RSV, 2 Influenza A and 1 - Parainfluenza 3).
Results: Etiology (cont.)
Of the 36 patients studied, 5 (mean age
2.6 years; range 0.4–5 years) had
atypical pneumonia diagnosed on the
basis of single IgM titre or four-fold
increase of IgG titre in paired sera (3 –
Chlamydia
pneumonia,
2
–
Mycoplasma pneumonia).
Values for different groups of
patients with CAP
CRP
PCT
WBC
Bacterial
pneumonia
69.9
(35-110)
0.87
(0.5-2.25)
12.0
(9.5-28)
Viral
pneumonia
4
(2-8)
0.18
(0.15-0.2)
7.3
(4-9)
Atypical
pneumonia
47.5
(20-75)
0.42
(0.2-1.9)
8.5
(6.5-12.4)
Results: CRP and PCT level
Children with bacterial and atypical
pneumonia had significantly higher
PCT level than those with viral
pneumonia.
The
significant
difference in PCT concentrations
was seen between bacterial and
atypical pathogens.
Results: CRP and PCT level (cont.)
The differences in the CRP levels
between
bacterial
and
viral
pneumonia were significant. No
significant differences in CRP level
were found between atypical and
viral or atypical and bacterial
pneumonia.
Conclusion
Both, serum PCT and CRP can
be used for differentiation
bacterial, atypical and viral
pneumonia in children, though
seems that the PCT is more
useful than CRP.