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Usefulness of Procalcitonin Levels in Community-Acquired Pneumonia According to the Patients Outcome Research Team Pneumonia Severity Index^*

^* From the Infectious Diseases Unit, Internal Medicine Department (Drs. Masiá, Gutiérrez, and Padilla), Pneumology Section (Dr. Shum), and Biochemistry Section (Drs. Navarro and Flores), Hospital General Universitario de Elche, Alicante; and Public Health Department (Dr. Hernández), Miguel Hernández University, Alicante, Spain.

Correspondence to: Mar Masiá, MD; Unidad de Enfermedades Infecciosas, Hospital General Universitario de Elche, Camí de la Almazara S/N; 03203 ELCHE, Alicante, Spain; e-mail: marmasia{at}ya.com

Study objectives: To evaluate the usefulness of procalcitonin serum levels as a predictor of etiology and prognosis in adult patients with community-acquired pneumonia (CAP) when they are stratified according to severity.

Design: One-year, population-based, prospective study.

Setting: University teaching hospital.

Patients: All adult patients who received a diagnosis of CAP throughout the study period.

Interventions and measurements: An extensive noninvasive microbiological workup was performed. In patients who gave informed consent, a blood sample was collected at the time the diagnosis of CAP was established to measure biological markers. Procalcitonin levels were measured by a commercially available monoclonal immunoluminometric assay (limit of detection, 0.1 µg/L). Patients were classified according to microbial diagnosis, Patients Outcome Research Team pneumonia severity index (PSI), and outcome measures, and procalcitonin levels were compared among groups.

Results: Of 240 patients who received a diagnosis of CAP during the study period, procalcitonin concentrations were measured in 185 patients (77.1%). Levels were higher in patients with high-severity risk classes (PSI classes III-V) [p = 0.01] and in those with complications (p = 0.03) or death (p < 0.0001). Among patients classified into PSI low-severity risk classes (classes I-II), levels tended to be higher in those with bacterial etiology (p = 0.08); in this group, a serum procalcitonin level 0.15 µg/L was more frequently found in patients with bacterial pneumonia than in those with nonbacterial pneumonia (p = 0.03). In patients with higher-severity risk classes, no significant differences were observed in procalcitonin levels among etiologic groups, but higher concentrations were associated with development of complications (p = 0.01) and death (p < 0.0001).

Conclusions: Procalcitonin contribution to the evaluation of CAP varies according to severity. While procalcitonin may have a role to predict the microbial etiology in patients with a low PSI score, in patients classified within high PSI risk classes, it is a prognostic marker rather than a predictor of etiology.

Key Words: biological markers • biomarkers • community-acquired pneumonia • etiology • outcome • pneumonia severity index • predictive scoring system • procalcitonin • prognosis