Ability of Procalcitonin to Predict

Bacterial Meningitis in the Emergency

Department
Clifford Eltin John - 01073180157
Jessica Pratiwi – 01073180125

Dibimbing oleh:
Dr. dr. Yusak MT Siahaan, Sp.S
Introduction
 Bacterial meningitis (BM) is an inflammatory process involving the
leptomeninges.
 Typical findings in cerebrospinal fluid (CSF) are marked pleocytosis (> 500-
1000 leukocytes/mm3, predominantly polymorphonuclear), elevated protein
levels, and low glucose levels
 The aetiology of BM tends to differ by age group.In younger adult patients,
Streptococcus pneumoniae (S.pneumoniae) and Neisseria meningitidis (N.
meningitidis) B are the most frequently isolated pathogens, but
otherpathogenic agents frequently found in patients aged 50 andolder include
Listeria monocytogenes (L. monocytogenes), Haemophilus influenzae (H.
influenzae), and gram-negative bacteria
 Non-specificity of clinical manifestations increases with age and is greater in
immunodepressed patients, diabetic patients, and others likely to experience
severe infections. In these patients, normal signs and symptoms do not
provide optimal sensitivity and specificity for distinguishing between
potential BM and viral meningitis (VM)
Aim

 To determine the diagnostic ability and utility of PCT for detecting BM,
predicting presence of bacteremia, and establishing a reliable cut-off point
for ruling out BM and bacteremia. These data are helpful for decision-making
in the ED (hospital admission, antibiotic use, performing blood cultures or
other microbiological tests).
Patients and Methods
Design
 Descriptive analytical study of patients diagnosed with AM in the ED. All
patients were monitored for 30 days or until death, regardless of whether
they remained in hospital or were discharged.
Study setting
 The study was conducted at Complejo Hospitalario de Toledo, a tertiary care
hospital with 786 beds, which serves as the reference center for a population
of 437 000 inhabitants. During the study period, we attended a mean of 435
emergency visits per day.
 Inclusion
 Age 15 and more
 Diagnosed with Acute Meningitis in the emergency dept between Aug 2009-July
2013
 Undergoes LP, blood culture tests, CRP, PCT
Included patients were categorised as follows:
1. Bacterial Meningitis,when either the pathogen or its capsular antigens were
isolated in CSF (in these cases, we also tested for conco-mitant bacteraemia)
2. Viral Meningitis, when polymerase chain reaction amplification detected herpes
viruses (DNA) and enteroviruses (RNA) in CSF;
3. Probable Viral Meningitis, when CSF and blood bacterial cultures were negative;
4. Presumptively diagnosed, partially treated Acute Meningitis, when patients had
been treated with antibiotics in the preceding 72 hours, and both blood and CSF
cultures were negative.
Exclusion
 Different potential primary focus of bacterial infection to avoid false-positive
results from biomarkers of infection and inflammation,
 Patients diagnosed with a second episode of Acute Meningitis during the study
period or a second episode of tuberculous or autoimmune meningitis during
follow-up
 Variable
 Sociodemographic variables (age, sex)
 Comorbidities, including presence of solid or oncohaematologicaltumours, liver disease, chronic
heart disease, kidney dis-ease, cerebrovascular disease, diabetes, HIV infection;
 immunosuppression (solid organ transplant recipients,splenectomised patients, patients treated
with ≥ 10 mg/dayof prednisone or equivalent for more than 30 days, or those treated with
immunosuppressants in the past year).
 Clinical symptoms fever (≥ 38◦C), hypothermia (< 35◦C), confu-sion or altered level/content of
consciousness, headache, nuchal rigidity, and signs of meningeal irritation (Kernig and
Brudzinski signs).
 Charlson comorbidity index
 Sepsis criteria established by the International Sepsis Definitions 2001
 Administration of antibiotic treatment in the previous 72 hours, time elapsed from symptom
onset to ED arrival, hospitalization time, and mortality rates during hospitalization and up to 30
days of diagnosis.
 The microbiological studies performed were blood and CSF cultures, and polymerase chain
reaction amplification of DNA (Herpesviridae) and RNA (Enterovirus).
 The analytical variables included results from complete blood tests, coagulation studies,
biochemical studies, and serum CRP and PCT measurements.
RESULT AND DISCUSSION
 PCT levels show significant differences
(11.47 ± 7.76 ng/mL vs 0.10 ± 0.15 ng/mL;P < .001).
 CRP has an AUC of 0.916 (95% CI,
0.838-0.994; P < .001) and therefore
its diagnostic utility is significantly
greater than that of the leukocyte
count.
 PCT, however, has the highest AUC
value of all the biomarkers (0.996;
95% CI, 0.987-1;P < .001).
 A cut-off point ≥ 0.74 ng/mL was
shown to have the greatest diagnostic
utility, achieving a sensitivity of
94.7% (95% CI, 82.2%-99.3%), a
specificity of 100% (95% CI,88.7%-
100%), an NPV of 93.9% (95% CI,
79.7%-99.2%), and a PPV of 100% (95%
CI, 90.2%-100%).
 For CRP, in turn, a cut-off point ≥ 90
mg/L achieves a sensitivity of 67.5%
(95% CI,50.2%-81.9%), a specificity of
86.3% (95% CI, 65%-97%), a PPV of
89.2% (95% CI, 71.7%-97.7%), and an
NPV of 90.4% (95% CI,69.6%-98.8%).
• Table 4 summarizes global results of comparisons between patients
with BM and bacteremia and those who doesn’t.
• CRP and PCT levels differed significantly (P < .05 in all cases) between
BM and VM subgroups. There were also significant differences (P < .
001) in mean PCT levels, but not in CRP, between patients with
probable VM (0.08 ± 0.05 ng/mL) and patients with BM (11.47 ± 7.76
ng/mL).
• Differences were also significant between patients with probable VM
and patients with presumptively diagnosed partially treated AM(0.81 ±
0.36 ng/mL; P = .003).
• AUC values for PCT level, CRP level,
and leukocyte count for determining
presence of bacteremia in BM.
• PCT presents a high diagnostic
utility for predicting bacteremia in
patients with BM.
• Its predictive ability is greater than
that of CRP and leukocyte count,
and its AUC is 0.965 (95% CI, 0.921
—1; P < .001).
• A cut-off point of 1.1 ng/mL has
been found to achieve the greatest
diagnostic utility, yielding a
sensitivity of 94.7% (95% CI, 73.9%-
99.8%),a specificity of 72.4% (95%
CI, 52.7%-87.8%), an NPV of 95.4%
(95% CI, 77.1%-99.8%), and a PPV
of 69.2% (95% CI,48.2%-85.6%).
Conclusion
 Both CRP and PCT significantly have more diagnostic utility than
leukocyte count
 PCT (94,7%; 100%) is more sensitive and specific than CRT (67.5%
86.3%)
 The diagnostic utility of PCT is significantly higher than that of CRP.
 PCT level has a high predictive ability for BM in emergency
department patients diagnosed with probable AM.
 PCT level displays a high predictive ability for bacteraemia in BM
cases confirmed by isolating the pathogen in CSF cultures.
 Unlike PCT, diagnostic utility of CRP is known to decrease in older
patients.
Conclusion

 Clinical manifestations become more non-specific with age, in immuno-

depressed patients, diabetic patients, and other patients likely to experience
severe infections.
 In such cases, normal signs and symptoms do not provide optimal sensitivity and
specificity for discriminating between potential cases of BM and VM.
 There are significant differences in PCT levels between patients with probable
VM (without a diagnosis) (0.08 ± 0.05) and both confirmed BM (P < .001) (11.47
± 7.76) and presumptively diagnosed partially treated AM (P = .003) (0.81 ±
0.36). When diagnosis is unclear, PCT may provide helpful clues for determining
the etiology of AM cases.
 PCT shows no significant differences for cases with N. meningitidis (P = .052)
and gram-negative bacteria (P = .405), but this may be due to the small sample
sizes in both subgroups.
Limitations
 Single-center study design and its small sample size
 This sample size was insufficient for some comparisons and may have affected
cut-off points and performance.
 The analysis did not include complications (encephalitis, seizures, etc.),
although this data might have provided more information.
 The lack of a healthy control group, which would have strengthened the
study’s internal validity.
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