ANNALS OF EMERGENCY MEDICINE
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2014
Systematic Review Snapshot TAKE-HOME MESSAGE Evidence is inadequate to support the use of procalcitonin as a test to rule in or rule out the diagnosis of endocarditis.
What Is the Role of Procalcitonin in Early Diagnosis of Infective Endocarditis?
METHODS
EBEM Commentators
DATA SOURCES EMBASE, MEDLINE, the Cochrane database, and reference lists of relevant articles were searched with no language restrictions through September 2013. STUDY SELECTION Studies that reported the diagnostic performance of procalcitonin alone or in comparison with other biomarkers to diagnose infective endocarditis were selected. DATA EXTRACTION AND SYNTHESIS Study methodological quality assessment was performed by the Quality Assessment of DiagnosticAccuracy Studies (QUADAS) instrument by 2 authors independently. The test performances were summarized with hierarchical summary receiver operating characteristic curves and a bivariate random-effects regression model.
Volume
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no.
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:
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2014
Manpreet Singh, MD Department of Emergency Medicine Harbor-UCLA Medical Center Torrance, CA
Alex Koyfman, MD Division of Emergency Medicine UT Southwestern Medical Center/Parkland Memorial Hospital Dallas, TX
Results Procalcitonin testing in diagnosis of endocarditis. Biomarker Procalcitonin
Sensitivity
Specificity
Positive LR
Negative LR
0.64 (0.52–0.74)*
0.73 (0.58–0.84)*
2.35 (1.40–3.95)*
0.64 (0.32–0.73)*
LR, Likelihood ratio. *95% Confidence interval.
Six articles met the inclusion criteria, with a total of 1,006 suspected infections that yielded 216 (21.5%) confirmed infective endocarditis infections. The study quality assessment based on the QUADAS tool indicated that all of the included studies were of good methodological quality; blood draws were in close proximity to confirmatory diagnosis and all patients were verified by the same reference standards. However, none of the studies explained withdrawals or reported uninterpretable results, and one study did not blind physicians to the index test when outcomes were verified by reference standards. Four of the studies used the Duke criteria,1,2 whereas the others used the modified Duke criteria as a reference diagnostic standard for infective endocarditis.3
Commentary Infective endocarditis is a disorder with a high mortality (12% to 30% within the first year). Frequent complications, such as cerebrovascular accidents (occurring in 15% to 20% of patients) caused by emboli or ruptured mycotic aneurysms, metastatic infection of viscera and bones, and valvular heart failure, can occur within the first 2 weeks. These complications result in an inhospital mortality of infective endocarditis of 15% to 22%,4 making this a disease entity that requires early recognition and treatment. The clinical presentation is often subtle early in the disease process, making it difficult to diagnose in the Annals of Emergency Medicine 1
Systematic Review Snapshot ED setting; cultures and advanced imaging (ie, transesophageal echocardiography) typically result in a delayed diagnosis.5,6 Therefore, a rapid biomarker assay could aid in establishing the diagnosis of infective endocarditis early enough to initiate antibiotic therapy in the acute care setting. Unfortunately, the results of this systematic review indicate that procalcitonin (including high- or lowsensitivity assays) is neither sensitive nor specific for infective endocarditis. The presence of fever, embolic phenomena, or new or changing murmurs, and the consideration of risk factors for endocarditis such as valvular heart disease (eg, the presence of prosthetic valve, intracardiac devices), intravenous drug use, and inadequately treated bacteremia, especially when due to Staphylococcus aureus,
2 Annals of Emergency Medicine
should prompt emergency physicians to consider infective endocarditis in the differential diagnosis.7 Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Yu C-W, Juan L-I, Hsu S-C, et al. Role of procalcitonin in the diagnosis of infective endocarditis: a meta-analysis. Am J Emerg Med. 2013;31:935-941. 1. Pierce D, Calkins BC, Thornton K. Infectious endocarditis: diagnosis and treatment. Am Fam Physician. 2012;85:10. 2. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med. 1994;96:200-209. 3. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633-638. 4. Hoen B, Duval X. Infective endocarditis. N Engl J Med. 2013;368:1425-1433.
5. Tleyjeh IM, Abdel-Latif A, Rahbi H, et al. A systematic review of population-based studies of infective endocarditis. Chest. 2007;132:1025-1035. 6. Timsit JF, Dubois Y, Minet C, et al. New challenges in the diagnosis, management, and prevention of central venous catheter–related infections. Semin Respir Crit Care Med. 2011;32:139-150. 7. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005;111:e394-e434.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
Volume
-,
no.
-
:
-
2014
-
2014
Systematic Review Snapshot TAKE-HOME MESSAGE Evidence is inadequate to support the use of procalcitonin as a test to rule in or rule out the diagnosis of endocarditis.
What Is the Role of Procalcitonin in Early Diagnosis of Infective Endocarditis?
METHODS
EBEM Commentators
DATA SOURCES EMBASE, MEDLINE, the Cochrane database, and reference lists of relevant articles were searched with no language restrictions through September 2013. STUDY SELECTION Studies that reported the diagnostic performance of procalcitonin alone or in comparison with other biomarkers to diagnose infective endocarditis were selected. DATA EXTRACTION AND SYNTHESIS Study methodological quality assessment was performed by the Quality Assessment of DiagnosticAccuracy Studies (QUADAS) instrument by 2 authors independently. The test performances were summarized with hierarchical summary receiver operating characteristic curves and a bivariate random-effects regression model.
Volume
-,
no.
-
:
-
2014
Manpreet Singh, MD Department of Emergency Medicine Harbor-UCLA Medical Center Torrance, CA
Alex Koyfman, MD Division of Emergency Medicine UT Southwestern Medical Center/Parkland Memorial Hospital Dallas, TX
Results Procalcitonin testing in diagnosis of endocarditis. Biomarker Procalcitonin
Sensitivity
Specificity
Positive LR
Negative LR
0.64 (0.52–0.74)*
0.73 (0.58–0.84)*
2.35 (1.40–3.95)*
0.64 (0.32–0.73)*
LR, Likelihood ratio. *95% Confidence interval.
Six articles met the inclusion criteria, with a total of 1,006 suspected infections that yielded 216 (21.5%) confirmed infective endocarditis infections. The study quality assessment based on the QUADAS tool indicated that all of the included studies were of good methodological quality; blood draws were in close proximity to confirmatory diagnosis and all patients were verified by the same reference standards. However, none of the studies explained withdrawals or reported uninterpretable results, and one study did not blind physicians to the index test when outcomes were verified by reference standards. Four of the studies used the Duke criteria,1,2 whereas the others used the modified Duke criteria as a reference diagnostic standard for infective endocarditis.3
Commentary Infective endocarditis is a disorder with a high mortality (12% to 30% within the first year). Frequent complications, such as cerebrovascular accidents (occurring in 15% to 20% of patients) caused by emboli or ruptured mycotic aneurysms, metastatic infection of viscera and bones, and valvular heart failure, can occur within the first 2 weeks. These complications result in an inhospital mortality of infective endocarditis of 15% to 22%,4 making this a disease entity that requires early recognition and treatment. The clinical presentation is often subtle early in the disease process, making it difficult to diagnose in the Annals of Emergency Medicine 1
Systematic Review Snapshot ED setting; cultures and advanced imaging (ie, transesophageal echocardiography) typically result in a delayed diagnosis.5,6 Therefore, a rapid biomarker assay could aid in establishing the diagnosis of infective endocarditis early enough to initiate antibiotic therapy in the acute care setting. Unfortunately, the results of this systematic review indicate that procalcitonin (including high- or lowsensitivity assays) is neither sensitive nor specific for infective endocarditis. The presence of fever, embolic phenomena, or new or changing murmurs, and the consideration of risk factors for endocarditis such as valvular heart disease (eg, the presence of prosthetic valve, intracardiac devices), intravenous drug use, and inadequately treated bacteremia, especially when due to Staphylococcus aureus,
2 Annals of Emergency Medicine
should prompt emergency physicians to consider infective endocarditis in the differential diagnosis.7 Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Yu C-W, Juan L-I, Hsu S-C, et al. Role of procalcitonin in the diagnosis of infective endocarditis: a meta-analysis. Am J Emerg Med. 2013;31:935-941. 1. Pierce D, Calkins BC, Thornton K. Infectious endocarditis: diagnosis and treatment. Am Fam Physician. 2012;85:10. 2. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med. 1994;96:200-209. 3. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633-638. 4. Hoen B, Duval X. Infective endocarditis. N Engl J Med. 2013;368:1425-1433.
5. Tleyjeh IM, Abdel-Latif A, Rahbi H, et al. A systematic review of population-based studies of infective endocarditis. Chest. 2007;132:1025-1035. 6. Timsit JF, Dubois Y, Minet C, et al. New challenges in the diagnosis, management, and prevention of central venous catheter–related infections. Semin Respir Crit Care Med. 2011;32:139-150. 7. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005;111:e394-e434.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
Volume
-,
no.
-
:
-
2014
