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Jaap T. van Dissel, Procalcitonin: What Should Be Its Role in the Clinical Management of Febrile Patients Admitted to the Hospital?, Clinical Infectious Diseases, Volume 36, Issue 6, 15 March 2003, Pages 824–825, https://doi.org/10.1086/368087
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SIR—I read with interest the article by Chirouze et al. [1]. In their study, measurement of serum procalcitonin (PCT) levels helped differentiate bacteremic from nonbacteremic infectious episodes in 165 acutely febrile patients admitted to the hospital. On the basis of their findings, Chirouze et al. [1] advocated routine measurement of serum PCT levels as guidance to determine whether or not to perform multiple blood cultures for and administer empirical antibiotic therapy to such patients.
To offer such broad advice regarding the clinical management of febrile patients on the basis of one study is, however, premature. For instance, the association of bacteremia at admission to the hospital with the subsequent morbidity and in-hospital death of patients with an acute infection is not strong enough to justify withholding empirical antibiotic treatment to patients with low PCT levels. In a study of 464 adult febrile patients admitted to the hospital, 90 patients had bacteremia and 33 patients died [2]. Of the patients who died, only 10 were bacteremic at admission (relative risk of in-hospital death due to bacteremia, 1.9; 95% CI, 0.9–4.2) [2]. The circulating concentration of proinflammatory microbial components, rather than the presence of whole, culturable bacterial cells, appeared relevant to the prediction of the course of disease. For example, of 48 patients who had gram-negative bacteremia—most cases of which were due to pyelonephritis—7 (29%) of the 24 patients with endotoxemia (endotoxin concentration [as determined by Limulus amoebocyte lysate assay], >5 pg/mL) died, whereas 0 of the 24 patients without endotoxemia died (P <.01) [2]. Thus, the clinical condition of the patient and the likely source of infection, rather than knowledge of the presence or absence of bacteremia, will dictate the administration of empirical antibiotic therapy to, for example, patients with pyelonephritis, erysipelas, cholangitis, and so on. Finally, the use of serum PCT levels as guidance for clinical management is premature because I could not confirm the very high negative predictive value of low PCT levels for determining the absence of bacteremia in acutely febrile patients.
