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Procalcitonin assay effectively diagnoses invasive bacterial infection in infants
According to recent data in JAMA Pediatrics, procalcitonin assay testing was more effective at identifying febrile infants at risk for invasive bacterial infections than urinalysis, but remained inferior for diagnosing severe bacterial infections.
“Our large prospective study reveals that procalcitonin is the best marker for identifying bacteremia and bacterial meningitis in febrile infants 7 to 91 days old and that it is moderately useful for identifying infants with severe bacterial infections,” Karen Milcent, MD, MSc, of the department of pediatrics at Antoine Béclère University Hospital in Clamart, France, and colleagues wrote. “However, urinalyses are reliable to detect severe bacterial infections, mainly represented by [urinary tract infection (UTI)] in this age group, contrary to invasive bacterial infection.”
The researchers analyzed samples from 2,047 febrile infants at 15 pediatric centers in France from October 2008 through March 2011. Clinicians recorded data related to demographics, fever history, clinical findings and clinical appearance.
Study findings revealed that 6.8% of participants were diagnosed with a severe bacterial infection, 5.6% were diagnosed with a UTI, and 1% were diagnosed with an invasive bacterial infection. Of the invasive bacterial infections, 13 were bacteremia, and eight were bacterial meningitis.
Procalcitonin assay testing returned an area under the curve of receiver operating characteristic curve similar to that of C-reactive protein (CRP) concentration for the detection of severe bacterial infection. It also returned a significantly higher AUC compared with CRP concentration (P = .002). At a threshold of 0.3 ng/mL, procalcitonin assay testing had a 90% sensitivity rate for invasive bacterial infection, compared with 74% for serious bacterial infection.
“The performance of procalcitonin testing should encourage the development of decision-making rules that incorporate procalcitonin,” Milcent and colleagues wrote. “Their effectiveness, cost, and the associated iatrogenic morbidity should be analyzed; these approaches should then be validated to determine how they should be combined to improve the management of febrile infants 7 to 91 days old.”
In a related editorial, Nathan Kuppermann, MD, MPH, of the department of pediatrics at the University of California Davis School of Medicine, and Prashant Mahajan, MD, MPH, MBA, of the pediatrics department at Children’s Hospital of Michigan wrote that Milcent and colleagues’ findings move diagnostic science closer to finding a “holy grail” for identifying febrile infants at risk for bacterial infection. They also highlighted some unaddressed limitations to the study.
“The investigators do not clearly describe how best to combine procalcitonin measurements with the clinical examination and/or other laboratory markers to obviate lumbar punctures and empirical antibiotic administration and hospitalization,” Kuppermann and Mahajan wrote. “An important next step in the quest will be to identify a viable alternative to culture-based approaches to identify which febrile infants truly have invasive bacterial infections.
“Ultimately, to achieve our goal of accurately identifying infants at high risk for invasive bacterial infections will require better clinical prediction rules, more precise screening tests, and a true gold standard for diagnosis.” – by David Costill
Disclosure: The researchers report no relevant financial disclosures.
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Kuppermann N, et al. JAMA Pediatr. 2015;doi:10.1001/jampediatrics.2015.3267.