J Infect Chemother xxx (2015) 1e3
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Note
The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection Takayuki Hoshina a, b, *, Tomoko Takimoto a, Etsuro Nanishi a, Hisanori Nishio a, Koichi Kusuhara b, Toshiro Hara a a b
Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 December 2014 Received in revised form 20 March 2015 Accepted 9 April 2015 Available online xxx
We investigated the utility of procalcitonin in early diagnosis of bacterial central nervous system (CNS) infection. Serum procalcitonin level was markedly elevated in the patients with systemic meningitis but not in the patients with brain abscess and subdural empyema. Procalcitonin may be useless to diagnose focal bacterial CNS infection. © 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Procalcitonin Brain abscess Subdural empyema Meningitis Focal bacterial infection
Procalcitonin is a useful marker not only in the diagnosis of severe bacterial infection such as sepsis and bacterial meningitis but also in the prediction of the prognosis of these diseases [1]. On the other hand, serum procalcitonin level is hard to be elevated in focal infection [2,3]. Early diagnosis and treatment for central nervous system (CNS) infection represented by bacterial meningitis and brain abscess are important because the mortality rate and the incidence of neurological sequelae are high in these diseases. The utilities of serum procalcitonin in the diagnosis and the prediction of prognosis of bacterial meningitis have been well known [1,4], whereas those of focal CNS infection such as brain abscess and subdural empyema are uncertain. To investigate the utility of procalcitonin in the diagnosis of focal bacterial CNS infection, we compared serum procalcitonin levels between the patients with meningitis due to hematogenous dissemination of bacteria and the patients with focal bacterial CNS infection. A retrospective cohort study on 20 patients less than 16 years old who were admitted to the Department of Pediatrics at Kyushu University Hospital from April 1, 2004 to March 31, 2013 for * Corresponding author. Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. Tel.: þ81 92 642 5421; fax: þ81 92 642 5435. E-mail address: [email protected] (T. Hoshina).
bacterial CNS infection was performed. Causative bacteria were detected from sterile sites in all patients. Of 20 patients, 14 patients diagnosed as having meningitis caused by hematogenous spread of bacteria were regarded as the group of systemic meningitis. Remaining six patients diagnosed as having brain abscess (n ¼ 2), subdural empyema (n ¼ 2) or bacterial meningitis due to ventriculoperitoneal (VP) shunt infection (n ¼ 2) were classified into the group of focal CNS infection. Clinical information and laboratory data on each patient were collected using a standardized case report form. The present study was approved by the Institutional Review Board of the Kyushu University. Comparisons of the quantitative values were analyzed by ManneWhitney U-test. The Fisher's exact test was applied for the qualitative analysis. p-values less than 0.05 were considered to be statistically significant. Of 14 patients with systemic meningitis, two patients were born as premature infant, and each patient had congenital protein C deficiency and atopic dermatitis as underlying disease, respectively. Causative pathogens were Haemophilus influenzae type b (n ¼ 7), Streptococcus pneumoniae (n ¼ 4) and Streptococcus agalactiae (n ¼ 3). Of six patients with focal CNS infection, two patients had sinusitis and each patient had double outlet right ventricle, congenital hydrocephalus and systemic lupus erythematosus as underlying diseases, respectively (Table 1). The patient with systemic lupus erythematosus was complicated by hydrocephalus due
http://dx.doi.org/10.1016/j.jiac.2015.04.003 1341-321X/© 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Hoshina T, et al., The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection, J Infect Chemother (2015), http://dx.doi.org/10.1016/j.jiac.2015.04.003
2
T. Hoshina et al. / J Infect Chemother xxx (2015) 1e3
Table 1 Clinical characteristics of the children with focal bacterial CNS infection. No.
Sex
Age
Diagnosis
Causative pathogen
Results of culture CSF
Blood
Focal site
WBCb (ml)
CRPb (mg/dl)
PCTb (ng/ml)
Underlying diseases
Sequelae
None
1
M
1y1m
Meningitis
S. epidermidis
Positive
Negative
Positivea
12,920
6.59
0.7
2 3 4
F F M
6y2m 10y1m 11y1m
Brain abscess Brain abscess Subdural empyema
S. mitis/oralis S. intermidius S. intermidius
N.D. N.D. Negative
Positive Negative Positive
N.D. Positive Positive
4910 8870 25,600
0.97 2.56 8.86
0.1 0.1 0.4
Hydrocephalus (VP shunt) None DORV Sinusitis
5
M
12y0m
S. pneumoniae
Positive
Negative
Positive
34,800
4.01
0.1
Sinusitis
6
M
15y11m
Subdural empyema, Meningitis Meningitis
None Transient paralysis Epilepsy, Transient paralysis Transient paralysis
S. epidermidis
Positive
Negative
Positivea
22,390
6.79
0.5
SLE, SAH (VP shunt)
None
S. epidermidis: Staphylococcus epidermidis, S. mitis/oralis: Streptococcus mitis/oralis, S. intermidius: Streptococcus intermidius, S. pneumoniae: Streptococcus pneumoniae, CNS: central nervous system, CSF: cerebral-spinal fluid, WBC: white blood cell, CRP: C-reactive protein, PCT: procalcitonin, VP shunt: ventriculoperitoneal shunt, DORV: double outlet right ventricle, SLE: systemic lupus erythematosus, SAH: subarachnoid hemorrhage, N.D.: not done. a Bacteria was detected from VP shunt tube. b Described data indicate the maximum level in the course of the infection.
to subarachnoid hemorrhage. Two patients with hydrocephalus underwent ventriculoperitoneal (VP) shunt placement. Causative pathogens in two patients with brain abscess were Streptococcus intermedius and Streptococcus mitis/oralis, respectively, and those in two patients with subdural empyema were S. intermedius and S. pneumoniae, respectively. Staphylococcus epidermidis was detected from cerebrospinal fluid in two patients with bacterial meningitis due to VP shunt infection. Blood culture also became positive in two patient diagnosed as having brain abscess due to S. mitis/ oralis and the patients diagnosed as having subdural empyema due to S. intermedius. The median age of the patients with focal CNS infection was higher than that of the patients with systemic meningitis (Table 2). The proportion of the patients with sequelae or complication was same between the two groups. None of these patients died during the present study. Serum CRP and procalcitonin levels were significantly higher than in the patients with systemic meningitis than in the patients with focal CNS infection (CRP: p ¼ 0.006, procalcitonin: p ¼ 0.0006) (Table 2). In particular, serum procalcitonin levels of all patients with systemic meningitis were more than 1.0 ng/ml, while those of all patients with focal CNS infection were less than 1.0 ng/ml (Table 1). In addition, serum procalcitonin level was significantly increased in the patients with systemic meningitis with sequelae or complication (data not shown). As in previous study [1,4], serum procalcitonin level was markedly elevated in the patients with meningitis caused by hematogenous spread of bacteria. Of these patients, the patients with sequelae or complication especially had high serum procalcitonin level, indicating that it is a useful marker for the prediction of severity and prognosis. On the other hand, serum procalcitonin level was limited to very mild elevation in the patients with focal
bacterial CNS infection such as brain abscess and subdural empyema. Even in CNS infection, procalcitonin is a useful marker for the diagnosis of systemic bacterial infection while it may be useless to diagnose focal bacterial infection. Morbidity of hematogenous bacterial meningitis in childhood beyond neonatal period had been declined dramatically after the introduction of pneumococcal conjugate vaccine and H. influenzae type b conjugate vaccine [5,6]. On the other hand, incidences of subdural empyema which develops due to the progression of sinusitis or otitis media, brain abscess which is likely to develop in the patients with congenital heart disease and device infection such as VP shunt have not decreased even after the introduction of these conjugate vaccines [7,8]. In fact, most of the causative pathogens of the patients diagnosed as having focal CNS infection were bacteria which could not be prevented by these conjugate vaccines. In contrast to hematogenous bacterial meningitis, the progression of focal CNS infection is slow, and low grade fever, headache and paralysis appear as initial symptoms of that disease [8]. Early diagnosis of focal CNS infection is difficult despite its poor prognosis. The detection of a useful marker for early diagnosis of that disease has been desired. In the present study, serum procalcitonin level was over 0.5 ng/ml, indicating severe systemic infection [9], in only one of 6 patients with focal bacterial CNS infection (Table 1). Furthermore, it was not elevated even in two patients having a positive culture from blood. Serum procalcitonin was hardly increased in local or mild systemic bacterial infection [3]. Spread of inflammation in focal CNS infection is limited to focal lesion, and the amount of bacteria in blood in the patients with focal CNS infection may be lower than those in the patients with systemic meningitis. In addition, younger children may be prone to excessive systemic inflammation. Although the total number of patients was
Table 2 Comparison of the clinical characteristics and laboratory data between the patients with systemic meningitis and those with focal CNS infection. Characteristics
Systemic meningitis (n ¼ 14)
Focal CNS infection (n ¼ 6)a
P
Age, months (range) Gender, % maile Number of the patients with sequelae or complication (%)b Day of illness obtained samples, median (range) White blood cell count, /ml, median (range) Neutrophil count, /ml, median (range) C-reactive protein, mg/dl, median (range) Procalcitonin, ng/ml, median (range)
7 (0e164) 57 7 (50) 2 (1e4) 10,645 (1980e34,490) 7552 (742e31,351) 16.71 (0.77e33.0) 18.35 (1.1e112)
127 (13e191) 67 3 (50) 2 (1e54) 17,655 (4910e34,800) 13,868 (2799e31,668) 5.30 (0.97e8.86) 0.25 (0.1e0.7)
0.007 1.0 1.0 0.96 0.40 0.40 0.006 0.0006
CNS: central nervous system. a Each two patients were diagnosed as having brain abscess, subdural empyema or bacterial meningitis via ventriculoperitoneal shunt, respectively. b In the patients with systemic meningitis, three patients had severe psychomotor retardation plus spastic quadriplegia, each one had deafness plus epilepsy, epilepsy, subdural empyema and subdural effusion, respectively. In the patients with focal bacterial CNS infection, one patient had transient paralysis plus epilepsy and two had transient paralysis.
Please cite this article in press as: Hoshina T, et al., The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection, J Infect Chemother (2015), http://dx.doi.org/10.1016/j.jiac.2015.04.003
T. Hoshina et al. / J Infect Chemother xxx (2015) 1e3
small, even in CNS infection, procalcitonin was hardly increased in focal bacterial infection, and the diagnostic performance of procalcitonin might be inferior to that of CRP. The diagnosis of focal bacterial CNS infection may have to depend on other markers and diagnostic imaging because of low priority of procalcitonin.
[4]
[5]
Conflict of interest None.
[6]
References [1] Carrol ED, Mankhambo LA, Jeffers G, Parker D, Guiver M, Newland P, et al. The diagnostic and prognostic accuracy of five markers of serious bacterial infection in Malawian children with signs of severe infection. PLoS One 2009;4:e6621. [2] Al Shuaibi M, Bahu RR, Chaftari AM, Al Wohoush I, Shomali W, Jiang Y, et al. Pro-adrenomedullin as a novel biomarker for predicting infections and response to antimicrobials in febrile patients with hematologic malignancies. Clin Infect Dis 2013;56:943e50. [3] Hoshina T, Nanishi E, Kanno S, Nishio H, Kusuhara K, Hara T. The utility of biomarkers in differentiating bacterial from non-bacterial lower respiratory tract infection in hospitalized children: difference of the diagnostic
[7] [8]
[9]
3
performance between acute pneumonia and bronchitis. J Infect Chemother 2014;20:616e20. Dubos F, Korczowski B, Aygun DA, Martinot A, Prat C, Galetto-Lacour A, et al. Serum procalcitonin level and other biological markers to distinguish between bacterial and aseptic meningitis in children: a European multicenter case cohort study. Arch Pediatr Adolesc Med 2008;162:1157e63. Martin NG, Sadarangani M, Pollard AJ, Goldacre MJ. Hospital admission rates for meningitis and septicaemia caused by Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae in children in England over five decades: a population-based observational study. Lancet Infect Dis 2014;14: 397e405. Shinjoh M, Iwata S, Yagihashi T, Sato Y, Akita H, Takahashi T, et al. Recent trends in pediatric bacterial meningitis in Japanea country where Haemophilus influenzae type b and Streptococcus pneumoniae conjugated vaccines have just been introduced. J Infect Chemother 2014;20:477e83. Cole TS, Clark ME, Jenkins AJ, Clark JE. Pediatric focal intracranial suppuration: a UK single-center experience. Childs Nerv Syst 2012;28:2109e14. Felsenstein S, Williams B, Shingadia D, Coxon L, Riordan A, Demetriades AK, et al. Clinical and microbiologic features guiding treatment recommendations for brain abscesses in children. Pediatr Infect Dis J 2013;32:129e35. Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, et al. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010;375: 463e74.
Please cite this article in press as: Hoshina T, et al., The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection, J Infect Chemother (2015), http://dx.doi.org/10.1016/j.jiac.2015.04.003
Contents lists available at ScienceDirect
Journal of Infection and Chemotherapy journal homepage: http://www.elsevier.com/locate/jic
Note
The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection Takayuki Hoshina a, b, *, Tomoko Takimoto a, Etsuro Nanishi a, Hisanori Nishio a, Koichi Kusuhara b, Toshiro Hara a a b
Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 December 2014 Received in revised form 20 March 2015 Accepted 9 April 2015 Available online xxx
We investigated the utility of procalcitonin in early diagnosis of bacterial central nervous system (CNS) infection. Serum procalcitonin level was markedly elevated in the patients with systemic meningitis but not in the patients with brain abscess and subdural empyema. Procalcitonin may be useless to diagnose focal bacterial CNS infection. © 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Keywords: Procalcitonin Brain abscess Subdural empyema Meningitis Focal bacterial infection
Procalcitonin is a useful marker not only in the diagnosis of severe bacterial infection such as sepsis and bacterial meningitis but also in the prediction of the prognosis of these diseases [1]. On the other hand, serum procalcitonin level is hard to be elevated in focal infection [2,3]. Early diagnosis and treatment for central nervous system (CNS) infection represented by bacterial meningitis and brain abscess are important because the mortality rate and the incidence of neurological sequelae are high in these diseases. The utilities of serum procalcitonin in the diagnosis and the prediction of prognosis of bacterial meningitis have been well known [1,4], whereas those of focal CNS infection such as brain abscess and subdural empyema are uncertain. To investigate the utility of procalcitonin in the diagnosis of focal bacterial CNS infection, we compared serum procalcitonin levels between the patients with meningitis due to hematogenous dissemination of bacteria and the patients with focal bacterial CNS infection. A retrospective cohort study on 20 patients less than 16 years old who were admitted to the Department of Pediatrics at Kyushu University Hospital from April 1, 2004 to March 31, 2013 for * Corresponding author. Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. Tel.: þ81 92 642 5421; fax: þ81 92 642 5435. E-mail address: [email protected] (T. Hoshina).
bacterial CNS infection was performed. Causative bacteria were detected from sterile sites in all patients. Of 20 patients, 14 patients diagnosed as having meningitis caused by hematogenous spread of bacteria were regarded as the group of systemic meningitis. Remaining six patients diagnosed as having brain abscess (n ¼ 2), subdural empyema (n ¼ 2) or bacterial meningitis due to ventriculoperitoneal (VP) shunt infection (n ¼ 2) were classified into the group of focal CNS infection. Clinical information and laboratory data on each patient were collected using a standardized case report form. The present study was approved by the Institutional Review Board of the Kyushu University. Comparisons of the quantitative values were analyzed by ManneWhitney U-test. The Fisher's exact test was applied for the qualitative analysis. p-values less than 0.05 were considered to be statistically significant. Of 14 patients with systemic meningitis, two patients were born as premature infant, and each patient had congenital protein C deficiency and atopic dermatitis as underlying disease, respectively. Causative pathogens were Haemophilus influenzae type b (n ¼ 7), Streptococcus pneumoniae (n ¼ 4) and Streptococcus agalactiae (n ¼ 3). Of six patients with focal CNS infection, two patients had sinusitis and each patient had double outlet right ventricle, congenital hydrocephalus and systemic lupus erythematosus as underlying diseases, respectively (Table 1). The patient with systemic lupus erythematosus was complicated by hydrocephalus due
http://dx.doi.org/10.1016/j.jiac.2015.04.003 1341-321X/© 2015, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Hoshina T, et al., The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection, J Infect Chemother (2015), http://dx.doi.org/10.1016/j.jiac.2015.04.003
2
T. Hoshina et al. / J Infect Chemother xxx (2015) 1e3
Table 1 Clinical characteristics of the children with focal bacterial CNS infection. No.
Sex
Age
Diagnosis
Causative pathogen
Results of culture CSF
Blood
Focal site
WBCb (ml)
CRPb (mg/dl)
PCTb (ng/ml)
Underlying diseases
Sequelae
None
1
M
1y1m
Meningitis
S. epidermidis
Positive
Negative
Positivea
12,920
6.59
0.7
2 3 4
F F M
6y2m 10y1m 11y1m
Brain abscess Brain abscess Subdural empyema
S. mitis/oralis S. intermidius S. intermidius
N.D. N.D. Negative
Positive Negative Positive
N.D. Positive Positive
4910 8870 25,600
0.97 2.56 8.86
0.1 0.1 0.4
Hydrocephalus (VP shunt) None DORV Sinusitis
5
M
12y0m
S. pneumoniae
Positive
Negative
Positive
34,800
4.01
0.1
Sinusitis
6
M
15y11m
Subdural empyema, Meningitis Meningitis
None Transient paralysis Epilepsy, Transient paralysis Transient paralysis
S. epidermidis
Positive
Negative
Positivea
22,390
6.79
0.5
SLE, SAH (VP shunt)
None
S. epidermidis: Staphylococcus epidermidis, S. mitis/oralis: Streptococcus mitis/oralis, S. intermidius: Streptococcus intermidius, S. pneumoniae: Streptococcus pneumoniae, CNS: central nervous system, CSF: cerebral-spinal fluid, WBC: white blood cell, CRP: C-reactive protein, PCT: procalcitonin, VP shunt: ventriculoperitoneal shunt, DORV: double outlet right ventricle, SLE: systemic lupus erythematosus, SAH: subarachnoid hemorrhage, N.D.: not done. a Bacteria was detected from VP shunt tube. b Described data indicate the maximum level in the course of the infection.
to subarachnoid hemorrhage. Two patients with hydrocephalus underwent ventriculoperitoneal (VP) shunt placement. Causative pathogens in two patients with brain abscess were Streptococcus intermedius and Streptococcus mitis/oralis, respectively, and those in two patients with subdural empyema were S. intermedius and S. pneumoniae, respectively. Staphylococcus epidermidis was detected from cerebrospinal fluid in two patients with bacterial meningitis due to VP shunt infection. Blood culture also became positive in two patient diagnosed as having brain abscess due to S. mitis/ oralis and the patients diagnosed as having subdural empyema due to S. intermedius. The median age of the patients with focal CNS infection was higher than that of the patients with systemic meningitis (Table 2). The proportion of the patients with sequelae or complication was same between the two groups. None of these patients died during the present study. Serum CRP and procalcitonin levels were significantly higher than in the patients with systemic meningitis than in the patients with focal CNS infection (CRP: p ¼ 0.006, procalcitonin: p ¼ 0.0006) (Table 2). In particular, serum procalcitonin levels of all patients with systemic meningitis were more than 1.0 ng/ml, while those of all patients with focal CNS infection were less than 1.0 ng/ml (Table 1). In addition, serum procalcitonin level was significantly increased in the patients with systemic meningitis with sequelae or complication (data not shown). As in previous study [1,4], serum procalcitonin level was markedly elevated in the patients with meningitis caused by hematogenous spread of bacteria. Of these patients, the patients with sequelae or complication especially had high serum procalcitonin level, indicating that it is a useful marker for the prediction of severity and prognosis. On the other hand, serum procalcitonin level was limited to very mild elevation in the patients with focal
bacterial CNS infection such as brain abscess and subdural empyema. Even in CNS infection, procalcitonin is a useful marker for the diagnosis of systemic bacterial infection while it may be useless to diagnose focal bacterial infection. Morbidity of hematogenous bacterial meningitis in childhood beyond neonatal period had been declined dramatically after the introduction of pneumococcal conjugate vaccine and H. influenzae type b conjugate vaccine [5,6]. On the other hand, incidences of subdural empyema which develops due to the progression of sinusitis or otitis media, brain abscess which is likely to develop in the patients with congenital heart disease and device infection such as VP shunt have not decreased even after the introduction of these conjugate vaccines [7,8]. In fact, most of the causative pathogens of the patients diagnosed as having focal CNS infection were bacteria which could not be prevented by these conjugate vaccines. In contrast to hematogenous bacterial meningitis, the progression of focal CNS infection is slow, and low grade fever, headache and paralysis appear as initial symptoms of that disease [8]. Early diagnosis of focal CNS infection is difficult despite its poor prognosis. The detection of a useful marker for early diagnosis of that disease has been desired. In the present study, serum procalcitonin level was over 0.5 ng/ml, indicating severe systemic infection [9], in only one of 6 patients with focal bacterial CNS infection (Table 1). Furthermore, it was not elevated even in two patients having a positive culture from blood. Serum procalcitonin was hardly increased in local or mild systemic bacterial infection [3]. Spread of inflammation in focal CNS infection is limited to focal lesion, and the amount of bacteria in blood in the patients with focal CNS infection may be lower than those in the patients with systemic meningitis. In addition, younger children may be prone to excessive systemic inflammation. Although the total number of patients was
Table 2 Comparison of the clinical characteristics and laboratory data between the patients with systemic meningitis and those with focal CNS infection. Characteristics
Systemic meningitis (n ¼ 14)
Focal CNS infection (n ¼ 6)a
P
Age, months (range) Gender, % maile Number of the patients with sequelae or complication (%)b Day of illness obtained samples, median (range) White blood cell count, /ml, median (range) Neutrophil count, /ml, median (range) C-reactive protein, mg/dl, median (range) Procalcitonin, ng/ml, median (range)
7 (0e164) 57 7 (50) 2 (1e4) 10,645 (1980e34,490) 7552 (742e31,351) 16.71 (0.77e33.0) 18.35 (1.1e112)
127 (13e191) 67 3 (50) 2 (1e54) 17,655 (4910e34,800) 13,868 (2799e31,668) 5.30 (0.97e8.86) 0.25 (0.1e0.7)
0.007 1.0 1.0 0.96 0.40 0.40 0.006 0.0006
CNS: central nervous system. a Each two patients were diagnosed as having brain abscess, subdural empyema or bacterial meningitis via ventriculoperitoneal shunt, respectively. b In the patients with systemic meningitis, three patients had severe psychomotor retardation plus spastic quadriplegia, each one had deafness plus epilepsy, epilepsy, subdural empyema and subdural effusion, respectively. In the patients with focal bacterial CNS infection, one patient had transient paralysis plus epilepsy and two had transient paralysis.
Please cite this article in press as: Hoshina T, et al., The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection, J Infect Chemother (2015), http://dx.doi.org/10.1016/j.jiac.2015.04.003
T. Hoshina et al. / J Infect Chemother xxx (2015) 1e3
small, even in CNS infection, procalcitonin was hardly increased in focal bacterial infection, and the diagnostic performance of procalcitonin might be inferior to that of CRP. The diagnosis of focal bacterial CNS infection may have to depend on other markers and diagnostic imaging because of low priority of procalcitonin.
[4]
[5]
Conflict of interest None.
[6]
References [1] Carrol ED, Mankhambo LA, Jeffers G, Parker D, Guiver M, Newland P, et al. The diagnostic and prognostic accuracy of five markers of serious bacterial infection in Malawian children with signs of severe infection. PLoS One 2009;4:e6621. [2] Al Shuaibi M, Bahu RR, Chaftari AM, Al Wohoush I, Shomali W, Jiang Y, et al. Pro-adrenomedullin as a novel biomarker for predicting infections and response to antimicrobials in febrile patients with hematologic malignancies. Clin Infect Dis 2013;56:943e50. [3] Hoshina T, Nanishi E, Kanno S, Nishio H, Kusuhara K, Hara T. The utility of biomarkers in differentiating bacterial from non-bacterial lower respiratory tract infection in hospitalized children: difference of the diagnostic
[7] [8]
[9]
3
performance between acute pneumonia and bronchitis. J Infect Chemother 2014;20:616e20. Dubos F, Korczowski B, Aygun DA, Martinot A, Prat C, Galetto-Lacour A, et al. Serum procalcitonin level and other biological markers to distinguish between bacterial and aseptic meningitis in children: a European multicenter case cohort study. Arch Pediatr Adolesc Med 2008;162:1157e63. Martin NG, Sadarangani M, Pollard AJ, Goldacre MJ. Hospital admission rates for meningitis and septicaemia caused by Haemophilus influenzae, Neisseria meningitidis, and Streptococcus pneumoniae in children in England over five decades: a population-based observational study. Lancet Infect Dis 2014;14: 397e405. Shinjoh M, Iwata S, Yagihashi T, Sato Y, Akita H, Takahashi T, et al. Recent trends in pediatric bacterial meningitis in Japanea country where Haemophilus influenzae type b and Streptococcus pneumoniae conjugated vaccines have just been introduced. J Infect Chemother 2014;20:477e83. Cole TS, Clark ME, Jenkins AJ, Clark JE. Pediatric focal intracranial suppuration: a UK single-center experience. Childs Nerv Syst 2012;28:2109e14. Felsenstein S, Williams B, Shingadia D, Coxon L, Riordan A, Demetriades AK, et al. Clinical and microbiologic features guiding treatment recommendations for brain abscesses in children. Pediatr Infect Dis J 2013;32:129e35. Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, et al. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010;375: 463e74.
Please cite this article in press as: Hoshina T, et al., The uselessness of procalcitonin in the diagnosis of focal bacterial central nervous system infection, J Infect Chemother (2015), http://dx.doi.org/10.1016/j.jiac.2015.04.003
