Procalcitonin use for the screening of bacterial infections in pregnant women in the emergency ward: A prospective study

We read with great interest the article by Velly and colleagues 1 Velly L. Volant S. Fitting C. et al. Optimal combination of early biomarkers for infection and sepsis diagnosis in the emergency department: the BIPS study. J Infect. 2021; 82: 11-21https://doi.org/10.1016/j.jinf.2021.02.019 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar which aimed at defining the best combination of biomarkers for the diagnosis of infection and sepsis in the emergency room. They report that the combination of IL6, procalcitonin and HLA-DR. was optimal to predict sepsis in their emergency room population. However, this study did not include pregnancy women. Indeed, maternal sepsis is a major cause of morbi-mortality in the pregnant host, and deciphering the cause of fever in the pregnant patient is paramount to address potentially life- or pregnancy-threatening conditions and limit useless and eventually harmful prescriptions. 2 Charlier C. Perrodeau E. Levallois C. et al. Causes of fever in pregnant women with acute undifferentiated fever: a prospective multicentric study. Eur J Clin Microbiol Infect Dis. 2020; 39: 999-1002https://doi.org/10.1007/s10096-019-03809-3 Crossref PubMed Scopus (2) Google Scholar Procalcitonin has shown to be an helpful biomarker to (i) discriminate viral and bacterial infections in adults with sepsis, meningitis, pneumonia, or sinusitis in primary care or emergency ward settings, 3 Vikse J. Henry B.M. Roy J. Ramakrishnan P.K. Tomaszewski K.A. Walocha J.A. The role of serum procalcitonin in the diagnosis of bacterial meningitis in adults: a systematic review and meta-analysis. Intern J Infect Dis. 2015; 38: 68-76https://doi.org/10.1016/j.ijid.2015.07.011 Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar ,4 Schuetz P. Albrich W. Mueller B. Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future. BMC Med. 2011; 9: 107https://doi.org/10.1186/1741-7015-9-107 Crossref PubMed Scopus (285) Google Scholar or in infants with pyelonephritis 5 Smolkin V. Koren A. Raz R. Colodner R. Sakran W. Halevy R. Procalcitonin as a marker of acute pyelonephritis in infants and children. Pediatr Nephrol. 2002; 17: 409-412https://doi.org/10.1007/s00467-001-0790-1 Crossref PubMed Scopus (80) Google Scholar and (ii) de-escalate antibiotic therapy 6 Briel M. Schuetz P. Mueller B. et al. Procalcitonin-guided antibiotic use vs a standard approach for acute respiratory tract infections in primary care. Arch Intern Med. 2008; 168: 2000https://doi.org/10.1001/archinte.168.18.2000 Crossref PubMed Scopus (299) Google Scholar without deleterious effect on morbi-mortality. 7 Schuetz P. Chiappa V. Briel M. Greenwald J.L. Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms. Arch Intern Med. 2011; 171: 1322-1331https://doi.org/10.1001/archinternmed.2011.318 Crossref PubMed Scopus (290) Google Scholar However, procalcitonin levels can remain in the normal range in localized infections such as tonsillitis, focal skin/soft tissue infections, and rise in non-infectious conditions such as delivery. 8 Paccolat C. Harbarth S. Courvoisier D. Irion O. de Tejada B.M. Procalcitonin levels during pregnancy, delivery and postpartum. J Perinat Med. 2011; 39: 679-683https://doi.org/10.1515/jpm.2011.082 Crossref PubMed Google Scholar The usefulness of this biomarker in the pregnant population has not been assessed yet beyond controversial performances in intra uterine infections. 9 Dulay A.T. Buhimschi I.A. Zhao G. et al. Compartmentalization of acute phase reactants Interleukin-6, C-reactive protein and procalcitonin as biomarkers of intra-amniotic infection and chorioamnionitis. Cytokine. 2015; 76: 236-243https://doi.org/10.1016/j.cyto.2015.04.014 Crossref PubMed Scopus (44) Google Scholar ,10 Thornburg L.L. Queenan R. Brandt-Griffith B. Pressman E.K. Procalcitonin for prediction of chorioamnionitis in preterm premature rupture of membranes. J Matern Fetal Neonatal Med. 2016; 29: 2056-2061https://doi.org/10.3109/14767058.2015.1077224 Crossref PubMed Scopus (18) Google Scholar Table 1Features by type of infection. Infection type* N= (%) Median Leucocytes count (/mm3) Median Polymorphonuclear cells count (/mm3) Median C-reactive protein level [25–75 IQ range] (mg/L) Median Procalcitonin level [25–75 IQ range] (µg/L) % C-reactive protein level < 5 mg/L N= (%) % Procalcitonin < 0.25 ng/mL N= (%) Antibiotic treatment prescribed after initial work-up N= (%) Bacterial 11/36 (31%) 12,500 11,000 86 [58.2;133.5] 0.47 [0.145;1.005] 0/11 4/11 (36%) 11/11 (100%) Pyelonephritis ✝ Pyelonephritis was retained in case of unilateral flank pain, and positive urine culture with ≥ 104 /mL of a single pathogen, namely Escherichia coli (n = 6), Klebsiella pneumoniae and Streptococcus sp. (n = 1, each). 8/36 (22%) 12,500 – – – 0/8 3/8 (38%) 8/8 (100%) Pneumonia ‡ Pneumonia was retained in case of respiratory symptoms combined with focal lung condensation area on chest X-ray. 1/36 (3%) – – – – 0/1 0/1 1/1 (100%) Sinusitis § Sinusitis was retained in case of unilateral purulent discharge combined with facial pain and > 7-days symptoms duration. Staphylococcus aureus was documented in one case. 2/36 (6%) 14,000 – – – 0/2 1/2 (50%) 2/2 (100%) Viral 25/36 (69%) 10,000 7000 28.8[17.7;45] 0.05 [0.04;0.07] 2/36 (4%) 25/25 (100%) 12/25 Influenza ¶ Influenza was confirmed by PCR amplification of viral RNA on a nasal swab sample (Influenza A and B, n = 6 and 7, respectively). 13/36 (36%) 12,000 8000 44.5 0.07 0/13 13/13 (100%) 7/13 Seasonal rhinopharyngitis Seasonal rhinopharyngitis was retained in case of bilateral nasal discharge with no evidence for sinusitis or lower respiratory tract infection. 10/36 (28%) 9000 7000 40.65 0.04 0/10 10/10 (100%) 4/10 Diarrhea/Norovirus ⁎⁎ Viral diarrhea was retained in case of acute diarrhea with PCR amplification of Norovirus RNA in one case; no bacterial pathogen was evidenced in the other case. 2/36 (6%) 12,900 – – – ½ (50%) 2/2 (100%) 1/2 IQ refers to 25–75 interquartile range. * Final diagnosis relied on a combination of clinical and microbiological features according to standard procedures. ✝ Pyelonephritis was retained in case of unilateral flank pain, and positive urine culture with ≥ 104 /mL of a single pathogen, namely Escherichia coli (n = 6), Klebsiella pneumoniae and Streptococcus sp. (n = 1, each). ‡ Pneumonia was retained in case of respiratory symptoms combined with focal lung condensation area on chest X-ray. § Sinusitis was retained in case of unilateral purulent discharge combined with facial pain and > 7-days symptoms duration. Staphylococcus aureus was documented in one case. ¶ Influenza was confirmed by PCR amplification of viral RNA on a nasal swab sample (Influenza A and B, n = 6 and 7, respectively). || Seasonal rhinopharyngitis was retained in case of bilateral nasal discharge with no evidence for sinusitis or lower respiratory tract infection. Viral diarrhea was retained in case of acute diarrhea with PCR amplification of Norovirus RNA in one case; no bacterial pathogen was evidenced in the other case. Open table in a new tab IQ refers to 25–75 interquartile range. * Final diagnosis relied on a combination of clinical and microbiological features according to standard procedures.