Charles Pierre Emmanuel, Tinel Claire, Barbar Saber, Aho Serge, Prin Sébastien, Doise Jean Marc, Olsson Nils Olivier, Blettery Bernard, Quenot Jean Pierre
Service de Réanimation Médicale, Hôpital Le Bocage, C,H,U, de Dijon, 21000 Dijon, France.
Crit Care. 2009;13(2):R38. doi: 10.1186/cc7751. Epub 2009 Mar 16.
Management of the early stage of sepsis is a critical issue. As part of it, infection control including appropriate antibiotic therapy administration should be prompt. However, microbiological findings, if any, are generally obtained late during the course of the disease. The potential interest of procalcitonin (PCT) as a way to assess the clinical efficacy of the empirical antibiotic therapy was addressed in the present study.
An observational cohort study including 180 patients with documented sepsis was conducted in our 15-bed medical intensive care unit (ICU). Procalcitonin measurement was obtained daily over a 4-day period following the onset of sepsis (day 1 (D1) to D4). The PCT time course was analyzed according to the appropriateness of the first-line empirical antibiotic therapy as well as according to the patient outcome.
Appropriate first-line empirical antibiotic therapy (n = 135) was associated with a significantly greater decrease in PCT between D2 and D3 (DeltaPCT D2-D3) (-3.9 (35.9) vs. +5.0 (29.7), respectively; P < 0.01). In addition, DeltaPCT D2-D3 was found to be an independent predictor of first-line empirical antibiotic therapy appropriateness. In addition, a trend toward a greater rise in PCT between D1 and D2 was observed in patients with inappropriate antibiotics as compared with those with appropriate therapy (+5.2 (47.4) and +1.7 (35.0), respectively; P = 0.20). The D1 PCT level failed to predict outcome, but higher levels were measured in the nonsurvivors (n = 51) when compared with the survivors (n = 121) as early as D3 (40.8 (85.7) and 21.3 (41.0), respectively; P = 0.04). Moreover, PCT kinetics between D2 and D3 were also found to be significantly different, since a decrease >or= 30% was expected in the survivors (log-rank test, P = 0.04), and was found to be an independent predictor of survival (odds ratio = 2.94; 95% confidence interval 1.22 to 7.09; P = 0.02).
In our study in an ICU, appropriateness of the empirical antibiotic therapy and the overall survival were associated with a greater decline in PCT between D2 and D3. Further studies are needed to assess the utility of the daily monitoring of PCT in addition to clinical evaluation during the early management of sepsis.
脓毒症早期的管理是一个关键问题。其中，包括及时给予适当抗生素治疗在内的感染控制应迅速进行。然而，微生物学检查结果（若有）通常在病程后期才能获得。本研究探讨了降钙素原（PCT）作为评估经验性抗生素治疗临床疗效方法的潜在价值。
在我们拥有15张床位的内科重症监护病房（ICU）对180例确诊脓毒症患者进行了一项观察性队列研究。在脓毒症发作后的4天内（第1天（D1）至D4）每天进行降钙素原检测。根据一线经验性抗生素治疗的适当性以及患者的预后分析PCT的时间进程。
适当的一线经验性抗生素治疗（n = 135）与D2至D3期间PCT的显著更大幅度下降相关（D2 - D3的PCT变化量（DeltaPCT D2 - D3）分别为-3.9（35.9）和+5.0（29.7）；P < 0.01）。此外，发现DeltaPCT D2 - D3是一线经验性抗生素治疗适当性的独立预测指标。另外，与接受适当治疗的患者相比，使用不适当抗生素的患者在D1至D2期间PCT有更大上升趋势（分别为+5.2（47.4）和+1.7（35.0）；P = 0.20）。D1时的PCT水平未能预测预后，但早在D3时，非幸存者（n = 51）的PCT水平高于幸存者（n = 121）（分别为40.8（85.7）和21.3（41.0）；P = 0.04）。此外，还发现D2至D3期间的PCT动态变化也有显著差异，因为预计幸存者的PCT会下降≥30%（对数秩检验，P = 0.04），并且发现这是生存的独立预测指标（比值比 = 2.94；95%置信区间1.22至7.09；P = 0.02）。
在我们ICU的研究中，经验性抗生素治疗的适当性和总体生存率与D2至D3期间PCT的更大幅度下降相关。在脓毒症早期管理中，除了临床评估外，还需要进一步研究评估每日监测PCT的效用。
