Procalcitonin as a Marker of Etiology in Adults Hospitalized With Community-Acquired Pneumonia

Self, Wesley H.; Balk, Robert A.; Grijalva, Carlos G.; Williams, Derek J.; Zhu, Yuwei; Anderson, Evan J.; Waterer, Grant W.; Courtney, D. Mark; Bramley, Anna M.; Trabue, Christopher; Fakhran, Sherene; Blaschke, Anne J.; Jain, Seema; Edwards, Kathryn M.; Wunderink, Richard G.

BACKGROUND. Recent trials suggest procalcitonin-based guidelines can reduce antibiotic use for respiratory infections. However, the accuracy of procalcitonin to discriminate between viral and bacterial pneumonia requires further dissection. METHODS. We evaluated the association between serum procalcitonin concentration at hospital admission with pathogens detected in a multicenter prospective surveillance study of adults hospitalized with community-acquired pneumonia. Systematic pathogen testing included cultures, serology, urine antigen tests, and molecular detection. Accuracy of procalcitonin to discriminate between viral and bacterial pathogens was calculated. RESULTS. Among 1735 patients, pathogens were identified in 645 (37%), including 169 (10%) with typical bacteria, 67 (4%) with atypical bacteria, and 409 (24%) with viruses only. Median procalcitonin concentration was lower with viral pathogens (0.09 ng/mL; interquartile range [IQR], <0.05–0.54 ng/mL) than atypical bacteria (0.20 ng/mL; IQR, <0.05–0.87 ng/mL; P = .05), and typical bacteria (2.5 ng/mL; IQR, 0.29–12.2 ng/mL; P < .01). Procalcitonin discriminated bacterial pathogens, including typical and atypical bacteria, from viral pathogens with an area under the receiver operating characteristic (ROC) curve of 0.73 (95% confidence interval [CI], .69–.77). A procalcitonin threshold of 0.1 ng/mL resulted in 80.9% (95% CI, 75.3%–85.7%) sensitivity and 51.6% (95% CI, 46.6%–56.5%) specificity for identification of any bacterial pathogen. Procalcitonin discriminated between typical bacteria and the combined group of viruses and atypical bacteria with an area under the ROC curve of 0.79 (95% CI, .75–.82). CONCLUSIONS. No procalcitonin threshold perfectly discriminated between viral and bacterial pathogens, but higher procalcitonin strongly correlated with increased probability of bacterial pathogens, particularly typical bacteria.