This case involves a 78-year-old female who presented with respiratory distress and was intubated. Her initial labwork showed an elevated white blood cell count, bands, and procalcitonin of 2.7 ng/mL, suggesting possible sepsis. She had multiple comorbidities including diabetes, hypertension, prior UTIs, and received TPN through a port. Her clinical picture and labs were concerning for sepsis possibly related to her port. Close monitoring of her procalcitonin and other markers over subsequent days would help guide management and predict her clinical course.
The research interest of the investigator has focused on the molecular and cellular pathogenesis of sepsis. In particular, he has worked on soluble proteins involved in the innate recognition of bacteria such as soluble CD14 and MD-2, as well as in the Toll-like receptors activated by Gram-negative and Gram-positive bacteria. Another area of study is the molecular pathogenesis and cell signaling of ventilator-induced lung injury, and lung inflammation in the context of acute respiratory distress syndrome. He has also identified and tested biomarkers in the field of clinical sepsis.
Watch the presentation on Youtube: https://www.youtube.com/watch?v=CyWN7JlhlmI&
The research interest of the investigator has focused on the molecular and cellular pathogenesis of sepsis. In particular, he has worked on soluble proteins involved in the innate recognition of bacteria such as soluble CD14 and MD-2, as well as in the Toll-like receptors activated by Gram-negative and Gram-positive bacteria. Another area of study is the molecular pathogenesis and cell signaling of ventilator-induced lung injury, and lung inflammation in the context of acute respiratory distress syndrome. He has also identified and tested biomarkers in the field of clinical sepsis.
Watch the presentation on Youtube: https://www.youtube.com/watch?v=CyWN7JlhlmI&
Presentations from the 1st May 2018 event Gram-negative Bloodstream infections: ensuring board assurance against national standards. Hosted by NHS Improvement and NHS England
SEPSIS IS MOST FATAL DISEASE WORLD WIDE. EARLY DETECTION OR PREDICTION OF SEPSIS IS A CHALLENGE
SEPSIS BIOMARKERS ARE OUR WEAPON TO EARLY DETECT SEPSIS. WE HAVE TO UNDERSTAND IT WELL
Serum Procalcitonin as a marker of infection in chronic kidney disease patien...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
poster presentation Study of hematological parameters in sepsis patients and...RahulGupta1687
The current study was a cross-sectional study with a sample size of 117 patients with sepsis. Various hematological parameters of all the patients were obtained on day of admission (day 1) and seventh day (day 7) using hemogram reports and the difference of their statistical mean and standard deviation was estimated.There was a significant statistical difference in the mean and standard deviation of neutrophil lymphocyte count ratio (NLCR), red cell distribution width standard deviation (RDW SD), Platelet count (PLT) and Platelet crit (PCT) whereas Mean platelet volume (MPV), Platelet distribution width (PDW) and Platelet large cell ratio (PLCR) showed no significant changes on day 1 and day 7 of observation in patients taken for the study.
The study to measure the level of serum annexin V in patients with renal hype...inventionjournals
ABSTRACT : Renovascular hypertension reflects the causal relation between anatomically evident arterial occlusive disease and elevated blood pressure. The coexistence of renal arterial vascular disease and hypertension roughly defines this type of nonessential hypertension. The aim of this study was to measure the level of serum Anti-Annexin V antibodies in patients with renal hypertension. Methods. This study was conducted on 115 patients, diagnosed with renal hypertension and hypertension. Informed consents were obtained from the patients and the study was approved by the Kharkiv National Medical University ethics committee. Ten healthy age and sex matched volunteers were included as a control group. All patients and controls were subjected to the following full history taking and thorough clinical examination. Routine laboratory testing included a complete blood count, and erythrocyte sedimentation rate (ESR) and kidney function tests (blood urea nitrogen and serum creatinine). Immunological tests for antinuclear antibody (ANA) and anticentromere antibodies (ACA) was performed by the indirect immunofluorescence technique. AntiScl-70 (anti-topoisomerase antibodies) and anticardiolipin antibodies (ACA: IgG and IgM) were tested using the ELISA technique. The anti-annexin V antibodies titre used the ZYMUTEST anti-Annexin IgG ELISA kit. [Hyphen-BioMed, France.]: to measure the IgG isotype of auto-antibodies to annexin V in human serum. Results. Anti-annexin V antibodies were present in 75% of patients (mean 83.46 ± 22.44 AU/mL) vs. 0% in the controls (mean 3.94 ± 4.5 AU/mL). Comparison between patients and controls as regards levels of anti-annexin V showed a highly significant difference (P < 0.001). Furthermore, correlation of anti-annexin V titres with the disease activity score in the patient group showed a statistically significant positive correlation (r = 0.51, P < 0.05).In addition, the anti-annexin V antibody titres in this study showed a highly significant positive correlation with ACL antibodies (r = 0.74, P < 0.001). Patients with antiphospholipid syndrome (APS) have been known to have a higher frequency of anti-annexin V antibodies, and thrombotic events have been reported more frequently in patients with positive anti-annexin V antibodies. Furthermore, inhibition of annexin V binding to negatively charged phospholipids may be an additional pathogenic mechanism of APS.
An Updated presentation of the management of severe sepsis including best evidence for fluid resuscitation, vasopressors, blood pressure target, steroid replacement, blood transfusion and other moralities.
Presentations from the 1st May 2018 event Gram-negative Bloodstream infections: ensuring board assurance against national standards. Hosted by NHS Improvement and NHS England
SEPSIS IS MOST FATAL DISEASE WORLD WIDE. EARLY DETECTION OR PREDICTION OF SEPSIS IS A CHALLENGE
SEPSIS BIOMARKERS ARE OUR WEAPON TO EARLY DETECT SEPSIS. WE HAVE TO UNDERSTAND IT WELL
Serum Procalcitonin as a marker of infection in chronic kidney disease patien...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
poster presentation Study of hematological parameters in sepsis patients and...RahulGupta1687
The current study was a cross-sectional study with a sample size of 117 patients with sepsis. Various hematological parameters of all the patients were obtained on day of admission (day 1) and seventh day (day 7) using hemogram reports and the difference of their statistical mean and standard deviation was estimated.There was a significant statistical difference in the mean and standard deviation of neutrophil lymphocyte count ratio (NLCR), red cell distribution width standard deviation (RDW SD), Platelet count (PLT) and Platelet crit (PCT) whereas Mean platelet volume (MPV), Platelet distribution width (PDW) and Platelet large cell ratio (PLCR) showed no significant changes on day 1 and day 7 of observation in patients taken for the study.
The study to measure the level of serum annexin V in patients with renal hype...inventionjournals
ABSTRACT : Renovascular hypertension reflects the causal relation between anatomically evident arterial occlusive disease and elevated blood pressure. The coexistence of renal arterial vascular disease and hypertension roughly defines this type of nonessential hypertension. The aim of this study was to measure the level of serum Anti-Annexin V antibodies in patients with renal hypertension. Methods. This study was conducted on 115 patients, diagnosed with renal hypertension and hypertension. Informed consents were obtained from the patients and the study was approved by the Kharkiv National Medical University ethics committee. Ten healthy age and sex matched volunteers were included as a control group. All patients and controls were subjected to the following full history taking and thorough clinical examination. Routine laboratory testing included a complete blood count, and erythrocyte sedimentation rate (ESR) and kidney function tests (blood urea nitrogen and serum creatinine). Immunological tests for antinuclear antibody (ANA) and anticentromere antibodies (ACA) was performed by the indirect immunofluorescence technique. AntiScl-70 (anti-topoisomerase antibodies) and anticardiolipin antibodies (ACA: IgG and IgM) were tested using the ELISA technique. The anti-annexin V antibodies titre used the ZYMUTEST anti-Annexin IgG ELISA kit. [Hyphen-BioMed, France.]: to measure the IgG isotype of auto-antibodies to annexin V in human serum. Results. Anti-annexin V antibodies were present in 75% of patients (mean 83.46 ± 22.44 AU/mL) vs. 0% in the controls (mean 3.94 ± 4.5 AU/mL). Comparison between patients and controls as regards levels of anti-annexin V showed a highly significant difference (P < 0.001). Furthermore, correlation of anti-annexin V titres with the disease activity score in the patient group showed a statistically significant positive correlation (r = 0.51, P < 0.05).In addition, the anti-annexin V antibody titres in this study showed a highly significant positive correlation with ACL antibodies (r = 0.74, P < 0.001). Patients with antiphospholipid syndrome (APS) have been known to have a higher frequency of anti-annexin V antibodies, and thrombotic events have been reported more frequently in patients with positive anti-annexin V antibodies. Furthermore, inhibition of annexin V binding to negatively charged phospholipids may be an additional pathogenic mechanism of APS.
An Updated presentation of the management of severe sepsis including best evidence for fluid resuscitation, vasopressors, blood pressure target, steroid replacement, blood transfusion and other moralities.
• Describe the role of antibiotic use in the
development of resistance
• Review toxicity of commonly used antibiotics
• Understand the prevalence and clinical impact
of carbapenem resistant enterobacteriaceae
• State the prognosis antimicrobial resistant
Staph aureus infections
•Describe the role of antibiotic use in the development of resistance
•Review toxicity of commonly used antibiotics
•Understand the prevalence and clinical impact of carbapenem resistant enterobacteriaceae
•State the prognosis antimicrobial resistant Staph aureus infections
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Room a a07. mcgee-procalcitonin to predict ss and guide therapy_(en)
1. Procalcitonin to Predict Septic Shock
& Guide Antibiotic Therapy
William T. McGee, M.D. MHA, FCCM, FCCP
Critical Care Medicine
Associate Professor of Medicine and Surgery
University of Massachusetts
759 Chestnut Street, Springfield, MA 01199
Tel: 413-794-5439 | Fax: 413-794-3987
william.mcgee@baystatehealth.org
2. 22
Role of PCT in sepsis
Alternative (non cytokine) pathway during sepsis: ‘Hormokine’
Bacterial toxins (gran +/gram-) and cytokines stimulate
production of Procalcitonin in all parenchymal cells
This process can be attenuated or blocked during viral
infection by interferons.
PCT is immediately released into the bloodstream
3. 33
Antibiotic misuse, inappropriate initiation and prolonged use
Safety risk to patients due to rise of antibiotic resistance
2 million illnesses and ~23,000 deaths per year in U.S.*
SERIOUS AND GROWING THREAT TO U.S.
AND GLOBAL PUBLIC HEALTH
*Centers for Disease Control and Prevention (CDC)
4. 44
Bacterial cultures can take 2-3 days
to perform
May have low sensitivity
Faster, more accurate indicators
of infection needed to make
critical antibiotic decisions
DIAGNOSING BACTERIAL INFECTION THAT WILL
RESPOND TO ANTIBIOTICS IS DIFFICULT
5. 55
Out of 69M people who are given antibiotics for respiratory issues,
annually in the U.S.
50% OF ANTIBIOTICS PRESCRIBED FOR
ACUTE RESPIRATORY CONDITIONS ARE
UNNECESSARY
34.3 Million
Get antibiotics unnecessarily
34.6 Million
Who need antibiotics get them
Shapiro D J, Antibiotic prescribing for adults in ambulatory care in the USA 2007–2009.
Journal of Antimicrobial Chemotherapy 2013.
6. 66
Misuse associated with drug toxicity, increased antibiotic
resistance, and collateral damage
Increased drug-resistant infections result in:
• More-serious illness or disability
• Higher death rate
• Prolonged recovery
• More-frequent or longer hospitalizations
Two common syndromes: Lower respiratory tract infection and
sepsis
WHEN USED INAPPROPRIATELY, ANTIBIOTICS
CARRY RISKS WITHOUT BENEFIT
7. 77
Procalcitonin
How can we use this cellular signal of infection
in the management of both septic and non
septic patients
Goals
Provide antibiotic therapy to pts who need it as soon
as possible
Avoid antibiotic prescription to those without infection
Do both with a strong likelihood of being correct, at
least as good as other markers such as WBC, bands,
fever, CRP
8. PCT kinetics provide important information on
prognosis of sepsis patients
• PCT levels, can be observed within 3-6 hours after an
infection with a peak - up to 1000 ng/ml - after 6-12 hrs.
Half-life: ~24hrs
• Specific to bacterial origin of infection and reflects the
severity of the infection Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892
9. 9
Simon L. et al. Clin Infect Dis. 2004; 39:206-217.
Adding PCT results to clinical assessment improves the
accuracy of the early clinical diagnosis of sepsis
• PCT levels accurately differentiate sepsis from noninfectious
inflammation*
• PCT is the best marker for differentiating patients with sepsis from
those with systemic inflammatory reaction not related to infection
Sensitivity: 89%
Specificity: 94%
NPV: 90% PPV:94%
10. 1010
PCT PROPERTIES FAVORABLE FOR ANTIBIOTIC
DECISION MAKING
*Nosocomial infection resulting from a single contaminated infusion at time 0
Brunkhorst et al. Intensive Care Med 1998;24:888-9
Data on file at bioMérieux Inc.
11. 1111
PCT LEVELS CORRELATE WITH DISEASE
SEVERITY
Harbath et al. Am J Respir Crit Care Med 2001;164:396-402
Data on file at bioMérieux Inc.
12. 1212
NPV = probability condition is absent given negative test
PCT LEVELS HAVE A HIGH NEGATIVE
PREDICTIVE VALUE IN LRTI
aRodriguez et al. J Infect 2016;72:143-51
bStolz et al. Swiss Med Wkly 2006;136:434-40
Data on file at bioMérieux Inc.
Endpoint
(Prevalence)
Sensitivity Specificity PPV NPV
Rodriguezaa
Confirmed
bacterial
co-infection
(20%)
90% 31% 25% 92%
Stolzb
Need for
antibiotics
(24%)
84% 98% 93% 94%
14. 14
Effect of Procalcitonin-Based Guidelines
vs. Standard Guidelines on Antibiotic Use
in Lower Respiratory Tract Infections:
The ProHOSP Randomized Controlled Trial
Philipp Schuetz, MD; Mirjam Christ-Crain, MD;
Robert Thomann, MD; Claudine Falconnier, MD;
Marcel Wolbers, PhD; Isabelle Widmer, MD;
Stefanie Neidert, MD; Thomas Fricker, MD;
Claudine Blum, MD; Ursula Schild, RN;
Katharina Regez, RN; Ronald Schoenenberger, MD;
Christoph Henzen, MD; Thomas Bregenzer, MD;
Claus Hoess, MD; Martin Krause, MD; Heiner C. Bucher, MD;
Werner Zimmerli, MD; Beat Mueller, MD
Journal of the American Medical Association.
2009;302(10):1059-1066.
15. 15
Overview
• Unnecessary antibiotic use
• Contributes to increasing bacterial resistance
• Increases medical costs and the risks
of drug-related adverse events
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
• Lower respiratory tract infections (LTRI)
– Most frequent indication for antibiotic prescriptions
in the Northwestern hemisphere
– 75% of patients are treated with antibiotics
– Predominantly viral origin of infection
• Procalcitonin (PCT) algorithm
– Reduced antibiotic use in patients with LTRIs
16. 16
Objective
Examine whether a PCT algorithm can
reduce antibiotic exposure without increasing
the risk for serious adverse outcomes.
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
Overview
17. 17
Multicenter, noninferiority, randomized controlled trial
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
Study Design
• Main Outcome Measures
– Composite adverse outcomes of death, intensive care
unit admission, disease-specific complications,
or recurrent infection within 30 days
– Antibiotic exposure and adverse effects from antibiotics
• Patients
– Randomized to administration of antibiotics based
on PCT algorithm
– Cutoff ranges for initiating or stopping antibiotics
(PCT group) or standard guidelines (control)
– Serum PCT was measured locally
18. 18
Flow Diagram of Patients in Trial
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
687 Randomized to
Receive Antibiotics Based
on PCT Algorithm
694 Randomized to
Receive Antibiotics Based
on Standard Guidelines
16 Withdrew Informed Consent
1 Lost to Follow-up
34 Died
6 Withdrew Informed Consent
0 Lost to Follow-up
33 Died
636 Completed 30-d Interview 655 Completed 30-d Interview
671 Included in Primary Analysis
16 Excluded
(Withdrew Informed Consent)
688 Included in Primary Analysis
6 Excluded
(Withdrew Informed Consent)
1381 Randomized
19. Results
No difference : death, intensive care
unit admission, disease-specific
complications,
or recurrent infection within 30 days
19
20. 20
SIMILAR RATES OF MORTALITY IN LRTI
PATIENT-LEVEL META-ANALYSIS
Data on file at bioMérieux.
21. 21
0
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
Antibiotic Exposure in Patients
Receiving Antibiotic Therapy
All Patients
(n = 1359)
Community-acquired Pneumonia
(n = 925)
PatientsReceiving
AntibioticTherapy,%
20
40
60
80
100
Time After Study Inclusion, d Time After Study Inclusion, d
0 1 2 5 7 9 11 >13
No. of Patients
PCT 506 484 410 306 207 138 72 46
Control 603 589 562 516 420 324 157 100
417 410 359 272 161 126 64 41
461 453 444 428 361 292 146 91
0 1 2 5 7 9 11 >13
PCT
Control
22. 22
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
0
PatientsReceiving
AntibioticTherapy,%
20
40
60
80
100
Time After Study Inclusion, d
0 1 2 5 7 9 11 >13
Time After Study Inclusion, d
0 1 2 5 7 9 11 >13
Exacerbation of COPD
(n = 228)
Acute Bronchitis
(n = 151)
No. of Patients
PCT 56 47 30 23 16 6 4 2
Control 79 78 67 56 40 20 5 4
16 11 9 3 3 1 1 1
41 38 35 19 8 3 0 0
PCT: Procalcitoin
COPD: Chronic Obstructive Pulmonary Disease
PCT
Control
Antibiotic Exposure in Patients
Receiving Antibiotic Therapy
23. 23
< 0.1 μg/l
NO antibiotics !
0.1 - 0.25 μg/l >0.5 μg/l>0.25 – 0.5 μg/l
No antibiotics Antibiotics YES !Antibiotics yes
Control PCT after 6-24 hours
Initial antibiotics can be considered in case of:
- Respiratory or hemodynamic instability
- Life-threatening comorbidity
- Need for ICU admission
- PCT < 0.1 μg/l: CAP with PSI V or CURB65 >3,
COPD with GOLD IV
- PCT < 0.25 μg/l: CAP with PSI ≥IV or CURB65 >2,
COPD with GOLD > III
- Localised infection (abscess, empyema),
L.pneumophilia
- Compromised host defense (e.g. immuno-
suppression other than corticosteroids)
- Concomitant infection in need of antibiotics
Bacterial etiology
very unlikely
Bacterial etiology
unlikely
Bacterial etiology
likely
Bacterial etiology
very likely
Procalcitonin (PCT) algorithm for stewardship of antibiotic therapy in patients with LRTI
Consider the course of PCT
If antibiotics are initiated:
- Repeated measurement of PCT on days 3, 5, 7
- Stop antibiotics using the same cut offs above
- If initial PCT levels are >5-10 μg/l, then
stop when 80-90% decrease of peak PCT
- If initial PCT remains high, consider treatment
failure (e.g. resistant strain, empyema, ARDS)
- Outpatients: duration of antibiotics according
to the last PCT result:
- >0.25-0.5 μg/l: 3 days
- >0.5 - 1.0 μg/l: 5 days
- >1.0 μg/l: 7 days
PCT: procalcitonin, CAP: community-acquired pneumonia, PSI: pneumonia severity index,
COPD: chronic obstructive pulmonary disease, GOLD: global initiative for obstructive lung disease
24. 24
Conclusions
An algorithm with PCT cutoff ranges was noninferior
to clinical guidelines in terms of adverse outcomes
death, intensive care
unit admission, disease-specific complications,
or recurrent infection within 30 days
Reduced antibiotic exposure
Reduced associated adverse effects
In countries with higher antibiotic prescription
rates PCT guidance may have clinical and
public health implications
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
26. Additional Results
Predictive value of baseline
PCT to determine + culture
(blood, urine, respiratory)
Positive vs. Negative culture
9.8ng/mL [1.7-41.3] vs.
3.3ng/mL[0.6-15.8] p<0.001
61% of cultures were positive
Predictive value of baseline
PCT to determine sepsis
severity
Septic shock vs. Sepsis
13.6ng/mL [2.7-55.2] vs.
3.6[0.5-15.6], p<0.001
Adapted from Shehabi Y et al. Procalcitonin algorithm in critically ill adults with undifferentiated infection or sepsis. Amer J Resp Crit Care Med 2014
Nov 15;190(10):1102-10
27. Additional Results
• Baseline PCT was similar in survivors and non-survivors
however there was a significantly faster decline overtime in the
serial PCT levels in survivors
• Baseline cut off of ≤ 3ng/mL excluded positive blood culture
with a sensitivity of 90% (95% CI, 82-89) and a NPV of 96% (95%
CI, 93-99)
• Baseline cut off of ≤ 0.1ng/mL excluded positive culture in the
first 72h with a sensitivity of 100% and NPV of 100%
Adapted from Shehabi Y et al. Procalcitonin algorithm in critically ill adults with undifferentiated infection or sepsis. Amer J Resp Crit
Care Med 2014 Nov 15;190(10):1102-10
30. 30
Case 1
78 y/o female found unresponsive at home by
family. Noted to be in respiratory distress.
Intubated in the ED for apnea. Prior h/o DM,
HTN, UTI, AV block, pacemaker, and AKA. In
ED WBC 14.6 with 31 bands, AG 14, BUN 53,
PCT 2.7. Patient had been receiving TPN via
porto-cath at home.
31. 31
Case 1
78 y/o female found unresponsive at home by family. Noted to be in
respiratory distress. Intubated in the ED for apnea. Prior h/o DM, HTN, UTI,
AV block, pacemaker, mild dimentia and AKA. In ED WBC 14.6 with 31
bands, AG 14, BUN 53, PCT 2.7. Patient had been receiving TPN via porto-
cath at home.
31
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Tmax
32. 32
Case 1
32
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Tmax
78 y/o female found unresponsive at home by family. Noted to be in
respiratory distress. Intubated in the ED for apnea. Prior h/o DM, HTN, UTI,
AV block, pacemaker, mild dimentia and AKA. In ED WBC 14.6 with 31
bands, AG 14, BUN 53, PCT 2.7. Patient had been receiving TPN via porto-
cath at home.
33. 33
Case 1
33
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Tmax
78 y/o female found unresponsive at home by family. Noted to be in
respiratory distress. Intubated in the ED for apnea. Prior h/o DM, HTN, UTI,
AV block, pacemaker, mild dimentia and AKA. In ED WBC 14.6 with 31
bands, AG 14, BUN 53, PCT 2.7. Patient had been receiving TPN via porto-
cath at home.
34. 34
Case 1
34
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Tmax
78 y/o female found unresponsive at home by family. Noted to be in
respiratory distress. Intubated in the ED for apnea. Prior h/o DM, HTN, UTI,
AV block, pacemaker, mild dimentia and AKA. In ED WBC 14.6 with 31
bands, AG 14, BUN 53, PCT 2.7. Patient had been receiving TPN via porto-
cath at home.
Porto-cath removed and
Antibiotics changed.
35. 35
Case 1
35
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Tmax
78 y/o female found unresponsive at home by family. Noted to be in
respiratory distress. Intubated in the ED for apnea. Prior h/o DM, HTN, UTI,
AV block, pacemaker, mild dimentia and AKA. In ED WBC 14.6 with 31
bands, AG 14, BUN 53, PCT 2.7. Patient had been receiving TPN via porto-
cath at home.
Porto-cath removed and
Antibiotics changed.
36. 36
Case 1
36
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Tmax
78 y/o female found unresponsive at home by family. Noted to be in
respiratory distress. Intubated in the ED for apnea. Prior h/o DM, HTN, UTI,
AV block, pacemaker, mild dimentia and AKA. In ED WBC 14.6 with 31
bands, AG 14, BUN 53, PCT 2.7. Patient had been receiving TPN via porto-
cath at home.
Porto-cath removed and
Antibiotics changed.
37. 37
Case 2
68 y/o male with h/o CHF, COPD, CAD
previously hospitlaized two months ago for
exacerbation of COPD. Presents with difficulty
breathing, SOB. No chest pain, but has cough
with clear to yellow sputum. ABG in ED
7.11/76/91 BNP 1301 Trop < .03 WBC 18,000,
0 Bands.
38. 38
Case 2
68 y/o male with h/o CHF, COPD, CAD previously hospitlaized two months
ago for exacerbation of COPD. Presents with difficulty breathing, SOB. No
chest pain, but has cough with clear to yellow sputum. ABG in ED
7.11/76/91 BNP 1301 Trop < .03 WBC 18,000, 0 Bands.
38
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Temp
39. 39
Case 2
68 y/o male with h/o CHF, COPD, CAD previously hospitlaized two months
ago for exacerbation of COPD. Presents with difficulty breathing, SOB. No
chest pain, but has cough with clear to yellow sputum. ABG in ED
7.11/76/91 BNP 1301 Trop < .03 WBC 18,000, 0 Bands.
39
0
Ng/mL
5
10
15
20
100
Days
0 1 2 3 4 5 6
PCT
WBC
Bands
Temp