Elsevier

Clinica Chimica Acta

Volume 489, February 2019, Pages 212-218
Clinica Chimica Acta

Recovery from childhood community-acquired pneumonia in a developing country: Prognostic value of serum procalcitonin

https://doi.org/10.1016/j.cca.2017.12.021Get rights and content

Highlights

  • Serum PCT level on admission < 0.25 ng/ml predicts rapid response to treatment.

  • Serum PCT level on admission < 0.25 ng/ml also predicts nonpneumococcal infection.

  • This cutoff has a high negative predictive value for pneumococcal infection.

  • This cutoff could contribute to identify who would not benefit from antibiotic use.

Abstract

Background

Childhood community-acquired pneumonia is a common and potentially life-threatening illness in developing countries. We assessed the prognostic value of serum procalcitonin level upon admission on clinical response to antibiotic treatment.

Methods

Out of 89 patients, the median (IQR) age was 19(12–29) months and 60% were boys. Viral (49.5%), typical bacterial (38%) and atypical bacterial (12.5%) infections as well as probable pneumococcal infections (26%) were diagnosed.

Results

Seventy-five (84%) children became afebrile ≤ 48 h after treatment. In 14 children who remained febrile after 48 h of treatment, median[IQR] serum procalcitonin (ng/ml) level on admission was higher than in those with rapid recovery (2.1[0.8–3.7] vs 0.6[0.1–2.2]; P = 0.025). In the slow-responding children, pneumococcal infections were more common (71% vs 17%; P < 0.001). Procalcitonin concentrations on admission were higher in children with pneumococcal pneumonia compared to children with non-pneumococcal pneumonia (2[0.7–4.2] vs 0.5[0.08–2.1]; P = 0.002). The ROC curve found that < 0.25 ng/ml of serum procalcitonin had a high negative predictive value (93%[95%CI:80%–99%]) for pneumococcal infection. All children that remained febrile after 48 h of treatment had procalcitonin > 0.25 ng/ml on admission. The majority of children with pneumonia in a developing country become afebrile within 48 h after onset of antibiotic treatment.

Conclusions

Serum procalcitonin < 0.25 ng/ml predicted rapid clinical response and non-pneumococcal etiology.

Introduction

Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality in children under-5 years in developing countries [1]. According to distinct guidelines, the chest radiograph (CXR) is useful in confirming the clinical diagnosis of CAP [2]. Etiologic diagnosis is rarely established in routine practice because lower respiratory tract specimens are difficult to obtain [3]. Currently, two diagnostic tools available to investigate bacterial infection are blood culture and blood polymerase chain reaction (PCR), both of which show low rate of positive results [3]. The etiologic agent frequency varies according to the age of the patients. Viral infection, however, is the most common one in all ages between the first month and the 5th year of life [4]. Russkanen et al. [5] showed that up to 85% of CAP episodes are caused by virus. The American and British guidelines have already recognized that not all children will benefit from antibiotic use [6], [7]. None of the clinical features, laboratory or radiologic findings, such as reactive-C protein or white blood cell count, though, could be associated to etiologic diagnosis on CAP [3]. Thus, antibiotic therapy is empirically used [2] and is probably over used as defining the causative agent remains a challenge in clinical practice. In this context, Penicillins are the first-line option because Streptococcus pneumoniae is the most frequent bacterial causative pathogen [2], [6], [7]. In a developed country, among children with pneumococcal bacteremic CAP, 94% became afebrile within 48 h of antibiotic treatment [8]. As such, resolution of fever has been considered a proxy of clinical response to antibiotic therapy [8], [9].

Procalcitonin (PCT) is a biomarker that has been studied in children with CAP as a predictor of bacterial infection and to guide antibiotic use [9], [10], [11]. In this context, we studied the prognostic value of serum PCT concentration on admission in regard to therapeutic response to aqueous penicillin G, stratified by etiology, among children hospitalized with CAP.

Section snippets

Study design

This was a prospective cohort conducted at the Emergency Room of the Federal University of Bahia hospital, in Salvador, Northeast Brazil, from September 2003 to May 2005. Community-dwelling children under-5 years diagnosed with CAP were enrolled. The diagnosis was made by the pediatrician on duty. Diagnosis was based upon fulfillment of the following criteria: 1) respiratory complaints plus 2) fever or difficulty breathing plus 3) pulmonary infiltrates on the CXR taken at admission. Exclusion

Results

Overall, 277 children were recruited: 209 (75%) had etiology determined and 159 (57%) had PCT measured; 113 had both, out of which 100 received aqueous penicillin G for treatment and 11 had pleural effusion detected at admission. Therefore, the study group comprised 89 children (Fig. 1). The clinical characteristics and duration of symptoms on admission of children hospitalized with CAP and probable etiology found, with or without serum PCT measurement were compared and there was no difference

Discussion

Our observations show that 84% of the children hospitalized due to CAP in a developing country become afebrile within 48 h after commencing penicillin treatment. Serum PCT level on admission < 0.25 ng/ml predicts rapid response to treatment and also predicts non-pneumococcal infection. The high negative predictive value of PCT < 0.25 ng/ml was confirmed when all children with PCT measured in serum collected upon admission were included in the analysis. This finding suggests that PCT may be useful at

Conclusion

PCT concentration < 0.25 ng/ml in children hospitalized with CAP predicts rapid response to antibiotic treatment and predicts nonpneumococcal infection. Children with pneumococcal pneumonia in a developing country may respond slower to treatment than those in a developed country.

Acknowledgments

The authors thank the pediatricians of the Emergency Room of the Federal University of Bahia Hospital, in Salvador, Brazil. This study was supported by the Bahia State Agency for Research Funding (FAPESB) and the Brazilian Council for Scientific and Technological Development in Brazil and the Foundation for Pediatric Research, in Finland.

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      Citation Excerpt :

      It is necessary to emphasize that none of the patients who did not receive antibiotics worsened or needed antibiotics afterwards.37 A Brazilian study described that serum PCT upon admission below 0.25 ng/dL had high negative predictive value for pneumococcal infection (93%; 95% CI:90–99%).38 It is important to highlight that, in both studies, patients had radiologically-confirmed pneumonia and, for that reason, even with a chest’s radiograph that confirms CAP diagnostics, it appears to be possible to identify those children who will not benefit from antibiotic use, for example, considering the serum PCT level <0.25 ng/mL.

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