A study of Community Acquired Pneumonia with respect to severity and prognosis by serum biomarkers and CURB 65 and SCAP scores.
Brief resume of the intended work:
Need For the study : Pneumonia is an infection of the pulmonary parenchyma.
It has been classified as Community-acquired (CAP),Hospital-acquired (HAP) and Ventilator-associated (VAP). Several studies have reported the clinical usefulness of serum procalcitonin, a biomarker of bacterial infection. The level of procalcitonin rises in a response to a proinflammatory stimulus, especially of bacterial origin.
It is produced mainly by the cells of the lung and the intestine.
Other biomarkers like CRP have also been mentioned various studies in assessing the severity of pneumonia and/complications. CURB-65 scoring and severe community acquired pneumonia scores which have been used in assessing the severity index of pneumonia and implicating its management. However there are very few studies which have assessed the complete usefulness of the biomarkers and have correlated with the severity indices. Hence this study intends to do the same.
Review of literature:
1. Simon et al. compared the predictive value of PCT and CRP in assessing the severity of CAP and found that PCT (88%) was more sensitive than CRP (75%) in the distinction of bacterial and noninfective causes of inflammation. Also, PCT (81%) was more specific than CRP (67%) in differentiating bacterial from noninfective causes of inflammation.
2. Kim JH et al , studied 155 CAP cases admitted to Pusan National University Hospital between January 2010 and December 2010. Patients were divided into two groups (≥65 years, n=99; <65 years, n=56) and were measured for procalcitonin, C-reactive protein (CRP), white blood cell, confusion, uremia, respiratory rate, blood pressure, 65 years or older (CURB-65) and pneumonia severity of index (PSI). They concluded that the levels of procalcitonin are more useful than the levels of CRP or WBC to predict the severity of CAP. However, there was no association between the levels of procalcitonin and mortality in the elderly.
3. S. Kru¨ger et al, studied about 1,671 patients with proven CAP were enrolled in the study. PCT, CRP, WBC and CRB-65 score were all determined on admission and patients were followed-up for 28 days for survival.
4. Pedro Póvoa et al studied A total of 891 patients (age 60 ± 17 yrs, hospital mortality 38%) . There were no significant differences between the CRP of survivors and non-survivors until Day 2 of antibiotic therapy. On the following three days, CRP of survivors was significantly lower (P < 0.001). After adjusting for the Simplified Acute Physiology Score II and severity of sepsis, the CRP course was significantly associated with mortality (ORCRP-ratio = 1.03,confidence interval 95%= (1.02, 1.04), P < 0.001). The hospital mortality of patients with fast response, slow response and no response patterns was 23%, 30% and 41%, respectively (P = 0.001). No responders had a significant increase on the odds of death (OR = 2.5, CI95% = (1.6, 4.0), P < 0.001) when compared with fast responders. They concluded, Daily CRP measurements after antibiotic prescription were useful as early as Day 3 in identification of
Community-Acquired Sepsis patients with poor outcome. The rate of CRP decline during the first five ICU days was markedly associated with prognosis. The identification of the pattern of CRP-ratio response was useful in the recognition of the individual clinical course.
6.3 Objectives of the study:
To study the predictive value of procalcitonin and CRP in the assessment of severity the CAP.
Assessing the severity of pneumonia using CURB65 and SCAP scoring method and comparing with the assessment with PCT and CRP levels.
Materials and Methods: SOURCE OF DATA:
All in-patients undergoing treatment in M.V.J. M.C and R.H.
METHOD OF COLLECTION OF DATA:
Study will be undertaken on patients with CAP of both sexes, aged 18 years & above.
All patients will be interviewed and clinically examined and investigated for serum procalcitonin levels and CRP levels. The severity of pneumonia using CURB65 and SCAP method will be assessed.
Informed consent will be obtained from all subjects for clinical examination. Patient confidentiality will be maintained.
Age > 18 yrs
A new pulmonary infiltrate diagnosed by clinical examination and chest x ray suggesting CAP.
HAP, VAP, HIV.
Hospitalisation > 4 weeks prior to infection.
7.3 Does the study require any investigation or interventions to be conducted on patients or other humans or animals? No investigations or interventions will be conducted on animals. Only routine investigations will be conducted on the patients
Informed written consent will be taken from the patients before conducting the investigations.
Patient confidentiality will be maintained.
7.4 Has ethical clearance been obtained from your institution in case of 7.3? YES
List of references:
. Rajeev Soman, Ayesha Sunavala, Journal of the association of physicians of India, July 2013.Vol.61. 14-19.
. S. Kruger, S. Ewig, R. Marre, J. Papassotiriou, K. Richter, H. von Baum et al, Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes. Eur Respir J 2008; 31: 349–355.
. Kim JH, Seo JW, Mok JH, Kim MH, Cho WH, Lee K, et al,Usefulness of plasma procalcitonin to predict severity in elderly patients with community-acquired pneumonia. Tuberc Respir Dis (Seoul). 2013 May;74(5):207-14. doi: 10.4046/trd.2013.74.5.207.
 Simon L Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis.2004 Jul 15;39(2):206-17
.Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
Society of merica/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin Inf Dis 2007;44:S27–72
. W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane BTS guidelines for the management of community acquired pneumonia in adults: update2009. Thorax 2009;64(III):iii1–iii55.
Signature of Candidate :
Remarks of the Guide :
Community acquired pneumonias are a group of conditions which are emerging as a main cause of hospital admissions and hence gaining importance. As a result, more and more alterations are being found now, towards their evaluation and management. A number of models and evaluation like CURB score have been introduced. Hence this study is undertaken to study the spectrum of CAP with reference to their diagnostic criteria, especially their relevance in the local setup.
PROFESSOR & HEAD OF THE DEPARTMENT OF GENERAL MEDICINE, MVJ MEDICAL COLLEGE & RESEARCH HOSPITAL
12.1 Remarks of the chairman & principal
INFORMED CONSENT FORM TOPIC: A study of Community Acquired Pneumonia with respect to severity and prognosis by serum biomarkers and CURB 65 and SCAP scores.
I ……………………………………………. declare that I have been briefed and hereby consent to be included as a subject in the following dissertation " A study of Community Acquired Pneumonia with respect to severity and prognosis by serum biomarkers and CURB 65 and SCAP scores. " I have been informed to my satisfaction by the attending doctor Dr. Ramesh Babu M, the purpose of the study. This has been explained to me in the language I understand and I fully consent for the same.