Neurocritical Care

, Volume 30, Issue 2, pp 440–448 | Cite as

Diagnostic Accuracy of Procalcitonin for Early Aspiration Pneumonia in Critically Ill Patients with Coma: A Prospective Study

  • Stéphane LegrielEmail author
  • Benedicte Grigoresco
  • Patricia Martel
  • Matthieu Henry-Lagarrigue
  • Virginie Lvovschi
  • Gilles Troché
  • Marlène Amara
  • Gwenaelle Jacq
  • Fabrice Bruneel
  • Maguy Bernard
  • Anne Marinier
  • Jean-Pierre Bedos
  • PCT INHAL study group
Original Article



Early diagnostic orientation for differentiating pneumonia from pneumonitis at the early stage after aspiration would be valuable to avoid unnecessary antibiotic therapy. We assessed the accuracy of procalcitonin (PCT) in diagnosing aspiration pneumonia (AP) in intensive care unit (ICU) patients requiring mechanical ventilation after out-of-hospital coma.


Prospective observational 2-year cohort study in a medical-surgical ICU. PCT, C-reactive protein (CRP) and white blood cell count (WBC) were measured at admission (H0) and 6 h (H), H12, H24, H48, H96, and H120 after inclusion. Lower respiratory tract microbiological investigations performed routinely in patients with aspiration syndrome were the reference standard for diagnosing AP. Performance of PCT, CRP, and WBC up to H48 in diagnosing AP was compared based on the areas under the ROC curves (AUC) and likelihood ratios (LR+ and LR−) computed for the best cutoff values.


Of 103 patients with coma, 45 (44%) had AP. Repeated PCT assays demonstrated a significant increase in patients with AP versus without AP from H0 to H120. Among the three biomarkers, PCT showed the earliest change. ROC-AUC values were poor for all three biomarkers. Best ROC-AUC values for diagnosing AP were for CRP at H24 [0.73 (95%CI 0.61–0.84)] and PCT at H48 [0.73 (95%CI 0.61–0.84)]. LR+ was best for PCT at H24 (3.5) and LR− for CRP and WBC at H24 (0.4 and 0.4, respectively).


Early and repeated assays of PCT, CRP, and WBC demonstrated significant increases in all three biomarkers in patients with versus without AP. All three biomarkers had poor diagnostic performance for ruling out AP. Whereas PCT had the fastest kinetics, PCT assays within 48 h after ICU admission do not help to diagnose AP in ICU patients with coma.


Pneumonia Critical care Mechanical ventilation Diagnostic techniques Neurological 



The study was supported by the Centre Hospitalier de Versailles, Versailles, France. We thank the nurses in our medical-surgical intensive care unit for their contribution to the study, M. Bouery-Veysseyre for logistic help, and A. Wolfe for help in preparing the manuscript.

Authors’ contributions

SL and JPB conceived, designed, and supervised the trial. All the investigators collected the data. SL and BG coordinated the data collection. PM was in charge of the statistical analysis. SL and BG analyzed and interpreted the data. MB and AM performed PCT assays. SL and BG wrote the first draft of the manuscript. All authors approved the final version of the manuscript.

Source of support

The study was supported by the Centre Hospitalier de Versailles, Versailles, France.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no competing interests.

Supplementary material

12028_2018_623_MOESM1_ESM.pptx (39 kb)
Patient flow chart
12028_2018_623_MOESM2_ESM.docx (18 kb)
Supplementary material 2 (DOCX 18 kb)
12028_2018_623_MOESM3_ESM.docx (21 kb)
Supplementary material 3 (DOCX 21 kb)


  1. 1.
    Leroy O, Vandenbussche C, Coffinier C, Bosquet C, Georges H, Guery B, et al. Community-acquired aspiration pneumonia in intensive care units. Epidemiological and prognosis data. Am J Respir Crit Care Med. 1997;156(6):1922–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Bronchard R, Albaladejo P, Brezac G, Geffroy A, Seince PF, Morris W, et al. Early onset pneumonia: risk factors and consequences in head trauma patients. Anesthesiology. 2004;100(2):234–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Lepelletier D, Roquilly A, Demeure dit latte D, Mahe PJ, Loutrel O, Champin P, et al. Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical-ICU head-trauma patients. J Neurosurg Anesthesiol. 2010;22(1):32–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665–71.CrossRefPubMedGoogle Scholar
  5. 5.
    Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol. 1946;52:191–205.CrossRefPubMedGoogle Scholar
  6. 6.
    Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia. Lancet. 1996;348(9020):123–4.CrossRefGoogle Scholar
  7. 7.
    Lascarrou JB, Lissonde F, Le Thuaut A, Bachoumas K, Colin G, Henry Lagarrigue M, et al. Antibiotic therapy in comatose mechanically ventilated patients following aspiration: differentiating pneumonia from pneumonitis. Crit Care Med. 2017;45(8):1268–75.CrossRefPubMedGoogle Scholar
  8. 8.
    Righy C, do Brasil PEA, Valles J, Bozza FA, Martin-Loeches I. Systemic antibiotics for preventing ventilator-associated pneumonia in comatose patients: a systematic review and meta-analysis. Ann Intensive Care. 2017;7(1):67.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Wacker C, Prkno A, Brunkhorst FM, Schlattmann P. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(5):426–35.CrossRefPubMedGoogle Scholar
  10. 10.
    El-Solh AA, Vora H, Knight PR 3rd, Porhomayon J. Diagnostic use of serum procalcitonin levels in pulmonary aspiration syndromes. Crit Care Med. 2011;39(6):1251–6.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Pusch F, Wildling E, Freitag H, Weinstabl C. Procalcitonin as a diagnostic marker in patients with aspiration after closed head injury. Wien Klin Wochenschr. 2001;113(17–18):676–80.PubMedGoogle Scholar
  12. 12.
    Mongardon N, Legriel S, Lemiale V, Cariou A. Prediction of neurological outcome after cardiac arrest: is serum procalcitonin the future? Neurocrit Care. 2010;13(1):159–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Mongardon N, Lemiale V, Perbet S, Dumas F, Legriel S, Guerin S, et al. Value of procalcitonin for diagnosis of early onset pneumonia in hypothermia-treated cardiac arrest patients. Intensive Care Med. 2010;36(1):92–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Albrich WC, Dusemund F, Bucher B, Meyer S, Thomann R, Kuhn F, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “real life”: an international, multicenter poststudy survey (ProREAL). Arch Intern Med. 2012;172(9):715–22.CrossRefPubMedGoogle Scholar
  15. 15.
    Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet. 2010;375(9713):463–74.CrossRefGoogle Scholar
  16. 16.
    Burkhardt O, Ewig S, Haagen U, Giersdorf S, Hartmann O, Wegscheider K, et al. Procalcitonin guidance and reduction of antibiotic use in acute respiratory tract infection. Eur Respir J. 2010;36(3):601–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Christ-Crain M, Stolz D, Bingisser R, Muller C, Miedinger D, Huber PR, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174(1):84–93.CrossRefGoogle Scholar
  18. 18.
    Schuetz P, Briel M, Mueller B. Clinical outcomes associated with procalcitonin algorithms to guide antibiotic therapy in respiratory tract infections. JAMA. 2013;309(7):717–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Schuetz P, Chiappa V, Briel M, Greenwald JL. Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms. Arch Intern Med. 2011;171(15):1322–31.CrossRefPubMedGoogle Scholar
  20. 20.
    Bafadhel M, Clark TW, Reid C, Medina MJ, Batham S, Barer MR, et al. Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD. Chest. 2011;139(6):1410–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Muller B, Harbarth S, Stolz D, Bingisser R, Mueller C, Leuppi J, et al. Diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia. BMC Infect Dis. 2007;7:10.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Bloos F, Marshall JC, Dellinger RP, Vincent JL, Gutierrez G, Rivers E, et al. Multinational, observational study of procalcitonin in ICU patients with pneumonia requiring mechanical ventilation: a multicenter observational study. Crit Care. 2011;15(2):R88.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Duflo F, Debon R, Monneret G, Bienvenu J, Chassard D, Allaouchiche B. Alveolar and serum procalcitonin: diagnostic and prognostic value in ventilator-associated pneumonia. Anesthesiology. 2002;96(1):74–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Luyt CE, Combes A, Reynaud C, Hekimian G, Nieszkowska A, Tonnellier M, et al. Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia. Intensive Care Med. 2008;34(8):1434–40.CrossRefPubMedGoogle Scholar
  25. 25.
    Ramirez P, Garcia MA, Ferrer M, Aznar J, Valencia M, Sahuquillo JM, et al. Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia. Eur Respir J. 2008;31(2):356–62.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Stéphane Legriel
    • 1
    • 2
    • 3
    Email author
  • Benedicte Grigoresco
    • 1
  • Patricia Martel
    • 4
  • Matthieu Henry-Lagarrigue
    • 1
  • Virginie Lvovschi
    • 1
  • Gilles Troché
    • 1
  • Marlène Amara
    • 5
  • Gwenaelle Jacq
    • 1
  • Fabrice Bruneel
    • 1
  • Maguy Bernard
    • 6
    • 7
  • Anne Marinier
    • 8
  • Jean-Pierre Bedos
    • 1
  • PCT INHAL study group
  1. 1.Medical-Surgical Intensive Care UnitCentre Hospitalier de Versailles - Site André MignotLe Chesnay CedexFrance
  2. 2.Sorbonne Paris Cité–Medical SchoolParis Descartes UniversityParisFrance
  3. 3.INSERM U970Paris Cardiovascular Research CenterParisFrance
  4. 4.Public Health DepartmentCentre Hospitalier Universitaire Ambroise ParéBoulogneFrance
  5. 5.Microbiology DepartmentCentre Hospitalier de Versailles - Site André MignotLe Chesnay CedexFrance
  6. 6.Department of Metabolic BiochemistryPitié Salpêtrière-Charles Foix University Hospital (AP-HP)ParisFrance
  7. 7.Department of Oncology and Endocrine BiochemistryPitié Salpêtrière-Charles Foix University Hospital (AP-HP)ParisFrance
  8. 8.Biochemistry DepartmentCentre Hospitalier de Versailles - Site André MignotLe Chesnay CedexFrance

Personalised recommendations