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The value of serum procalcitonin among

exacerbated COPD patients

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DOI: 10.1016/j.ejcdt.2015.05.016

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Egyptian Journal of Chest Diseases and Tuberculosis (2015) xxx, xxx–xxx

H O S T E D BY
The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

www.elsevier.com/locate/ejcdt
www.sciencedirect.com

ORIGINAL ARTICLE

The value of serum procalcitonin among

exacerbated COPD patients
a,* b
Ashraf Abd El Halim , Manal Sayed

a
Chest Department, Faculty of Medicine, Zagazig University, Egypt
b
Clinical Pathology Department, Egyptian Central Laboratories, Egypt

Received 11 March 2015; accepted 26 May 2015

KEYWORDS Abstract Acute exacerbation of COPD (AECOPD) is an important but occasionally overlooked
Procalcitonin; parameter. COPD exacerbations are very common, affecting about 20% of COPD patients. The
COPD; bacterial infection plays an important role in the exacerbation of COPD patients. Quick and accu-
Acute exacerbation; rate recognition of these patients along with aggressive and prompt intervention may be the only
Mechanical ventilation action that prevents frank respiratory failure.
Aim of the work: The aim of this work is to clarify the role of serum procalcitonin in predicting
the bacterial exacerbations of COPD patients and their needs for mechanical ventilation.
Methods: 30 COPD patients with bacterial exacerbations, 23 stable COPD patients and 20
healthy control subjects of similar age and sex were included in the study. PCT levels in the serum
samples were measured in all subjects.
Results: There was a highly statistically significant difference (p value <0.001) between
AECOPD patients (1.44 ± 0.542 ng/ml) on one side and stable COPD patients
(0.05 ± 0.012 ng/ml) and healthy control subjects (0.04 ± 010 ng/ml) on the other side regarding
the mean values of PCT. Also, we found a statistically significant difference (p value <0.05)
between AECOPD patients infected with Pseudomonas aeruginosa and AECOPD patients infected
with other bacteria regarding the mean serum levels of PCT. A statistically significant difference (p
value <0.001) was present among AECOPD patients that needed ventilatory support
(2.024 ± 0.564 ng/ml) and those did not need mechanical ventilation (1.262 ± 0.399 ng/ml). We
detected a highly statistically positive correlation (p value <0.001) between PCT serum levels,
CRP (r = 0.662) and WBC count (r = 0.591). Also, we found a highly statistically negative
correlation (p < 0.05) between PCT serum levels and FEV1 (r = 0.625).
Conclusions: This study found increased PCT serum levels among AECOPD patients and sug-
gests a role for PCT in the predicting of the bacterial exacerbations and their needs for ventilatory
support. We recommend other large studies to augment our findings.
ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest
Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. Mobile: +20 01100214951.

E-mail address: ashrafaeh@gmail.com (A.A. El Halim).
Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
0422-7638 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: A.A. El Halim, M. Sayed, The value of serum procalcitonin among exacerbated COPD patients, Egypt. J. Chest Dis. Tuberc. (2015),
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
2 A.A. El Halim, M. Sayed
Introduction
Chronic obstructive pulmonary disease (COPD) is a major
public health problem. It is the fourth leading cause of chronic
morbidity and mortality in the United States, and is projected
to rank fifth in 2020 in burden of disease caused worldwide,
according to a study published by the World Bank/World
Health Organization [1].
Patients with COPD are susceptible to many insults that
can lead rapidly to an acute deterioration superimposed on
chronic disease. Acute exacerbation of COPD (AECOPD) is
an important but occasionally overlooked parameter. COPD
exacerbations are very common, affecting about 20% of
patients with moderate-to-severe COPD (1.3 events per year
in patients with 40–45% predicted FEV1). The bacterial infec-
tion plays an important role in the exacerbation of COPD
patients. Quick and accurate recognition of these patients
along with aggressive and prompt intervention may be the only
action that prevents frank respiratory failure [2].
Procalcitonin (PCT) is a peptide precursor of hormone cal-
citonin, the later being involved with calcium homeostasis. It is
composed of 116 amino acids and is produced by the parafol-
licular cells (C cells) of the thyroid and by the neuroendocrine
cells of the lung and the intestine [3]. The level of procalcitonin
raises in a response to a proinflammatory stimulus, especially
of bacterial origin. The investigations identified PCT as part
of the complex pro-inflammatory response of the innate
immune system. In vitro stimulation of macrophages with
either bacteria or endotoxin results in rapid synthesis and
release of tumor necrosis factor, (TNF), interleukin (IL) -1,
and IL-6 [4]. Serum PCT serum levels are detectable as early
as 3–4 h after the invasion, which is much earlier than the
increase in the C-reactive protein level or erythrocyte sedimen-
tation rate [5,6]. Thus far, elevated PCT levels have not been
noted for other inflammatory conditions, such as inflamma-
tory bowel disease, temporal giant cell arteritis, polyarteritis
nodosa, systemic lupus erythematosus, gout, and Still disease
[7–10]. Available data indicate that PCT levels are not
influenced by therapy with glucocorticoids or nonsteroidal
anti-inflammatory agents [11,12]. PCT levels do not increase
or increase only modestly in patients with infection due to
respiratory viruses [13,14].
Aim of the work
The aim of this work is to clarify the role of the serum procal-
citonin in predicting the bacterial exacerbations of COPD
patients and their needs for mechanical ventilation.
Subjects and methods
This study was conducted at our university hospitals. A con-
sent was taken from each included subject. The study included
3 groups of subjects (Table 1):
Group 1: It included 30 bacteriologically confirmed exacer-
bated COPD that admitted in the hospital. The mean age was
60.52 ± 11.07. There were 21 (70%) males and 9 (30%) females.
Group 2: It included 23 stable COPD under follow up at
outpatient department. The mean age was 58.60 ± 10.44.
There were 15 (65.22%) males and 8 (34.78%) females.
Please cite this article in press as: A.A. El Halim, M. Sayed, The value of serum procalcitonin among exacerbated COPD patients, Egypt. J. Chest Dis. Tuberc. (2015),
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
Group 3: It included 20 healthy control subjects. The mean
age was 58.35 ± 9.25. There were 13 (65%) males and 7 (35%)
females.
The three groups were matched for age and sex (p value
>0.05).
The subjects included in this study had undergone the
following:
(1) Complete history taking and physical examination.
(2) Chest x ray examination.
(3) Complete blood picture (CBC).
(4) C reactive protein (CRP).
(5) Arterial blood gas analysis (ABGs).
(6) Bacteriological diagnostic tests for sputum, tracheo-
bronchial secretions and blood for exacerbating COPD
patients only. Serum antibodies titers (a 4-fold or more
increase in paired sera titers or a single titer greater than
or equal to 1:32) supported the diagnosis of mycoplasma
and chlamydial infections.
(7) Measurement of procalcitonin: This was done in all sub-
jects included in this study. Blood samples were taken
and the sera were separated and stored at 80 C for
further procalcitonin analysis. Procalcitonin levels were
determined with the commercially available automated
immunochemistry method (Brahms Kryptor, Brahms
Liaison, Berlin, Germany) [15].
Exclusion criteria
Any patient having any one of the following was excluded
from this study: (1) history of recent antibiotic therapy before
admission, (2) Evidence of pneumonia on chest radiograph; (3)
Evidence of bacterial infection elsewhere; (4) Immuno-
suppression; (5) Negative bacteriological diagnostic tests.
The diagnosis of COPD was established by clinical
symptoms, physical examination, chest radiography and pul-
monary function tests according to the guidelines of GOLD
[1]. The COPD subjects were classified into (stages I–IV) on
the basis of their post-bronchodilator forced expiratory
volume in one second (FEV1)/forced vital capacity (FVC)
and FEV 1% predicted. FEV1/FVC was <70% and their
FEV1 fell into set bands (stage 1: FEV1 P 80%; stage 2:
50% P FEV1 < 80%; stage 3: 30% P FEV1 < 50%; stage
4: FEV1 < 30%).
Stable chronic obstructive pulmonary disease
Stable COPD is defined by the absence of any exacerbation for
3 months preceding the study [16].
Acute exacerbation of COPD (AECOPD)
The American Thoracic Society (ATS) and European
Respiratory Society (ERS) define an exacerbation as an acute
change in a patient’s baseline dyspnea, cough, or sputum that
is beyond normal variability, and that is sufficient to warrant a
change in therapy [17]. AECOPD was considered bacteriolog-
ically confirmed in the presence of a positive Gram stain of res-
piratory samples, a pathogen concentration greater than
105 cfu/ml in tracheobronchial aspirations, a blood culture,
Value of serum procalcitonin among exacerbated COPD patients 3

revealing a bacterial pathogen in the absence of an extrapul-

Table 2 Comparison between different subject groups regard-
monary focus, or positive serological tests [18].
ing PCT levels (ng/ml).
Statistical analysis Groups PCT Mean ± SD p Value
(ng/ml)

Statistical analysis was performed with the Statistical Package 1. AECOPD patients 1.44 ± 0.542 1 vs 2 < 0.01
for the Social Sciences, version 16 for Windows (SPSS Inc., 2. Sable COPD patients 0.05 ± 0.012 1 vs 3 < 0.01
3. Control subjects 0.04 ± 0.010 2 vs 3 > 0.05
Chicago, IL, USA). Values of p < 0.05 were considered statis-
tically significant.

Results In this work 7 AECOPD patients required ventilator sup-

There was a highly statistically significant difference (p value
<0.001) between AECOPD patients on one side and stable
COPD patients and healthy control subjects on the other side
regarding the mean values of PCT (1.44 ± 0.542 ng/ml among
AECOPD patients, 0.05 ± 0.012 ng/ml among stable COPD
patients, 0.04 ± 010 ng/ml among healthy control subjects)
(Table 2 and Fig. 1). No statistically significant difference (p
value >0.05) in the mean values of PCT was present among
non stable COPD patients and healthy control subjects
(0.05 ± 0.012 ng/ml among stable COPD patients, 0.04 ±
010 ng/ml among healthy control subjects) (Table 2 and Fig. 1).
The causative microbes among AECOPD patients were
shown in Table 3. Gram negative bacteria caused exacerbation
in 66.33% of the patients, Gram positive bacteria in 23.33% of
them and atypical bacteria in 13.34% of the patients.
Haemophilus influenzae (30%) was the most common organism
followed by Streptococcus pneumoniae (23.33%), Pseudomonas
aeruginosa (23.33%), Moraxella catarrhalis (10%),
Mycoplasma pneumoniae (6.67% and Chlamydia pneumoniae
(6.67%).
This study found a statistically significant difference (p
value <0.05) between AECOPD patients infected with P.
aeruginosa and AECOPD patients infected with other bacteria
regarding the mean serum levels of PCT (Table 4). The cutoff
value of 1.215 ng/ml PCT serum level has 66.7% sensitivity
and 100% specificity for P. aeruginosa. The area under the
curve was 0.836 (Fig. 2).
port. All these patients weaned successfully. None of these
patients died. A statistically significant difference (p value
<0.001) was present among AECOPD patients that needed
ventilatory support (2.024 ± 0.564 ng/ml) and those did not
need mechanical ventilation (1.262 ± 0.399 ng/ml) (Table 5
and Fig. 3). At cutoff 1.495 ng/ml, PCT had 85.7% sensitivity
and 78.3% specificity for predicting AECOPD patients that
needed ventilatory support. The area under the curve was
0.891 (Fig. 4).
We detected a highly statistically positive correlation (p
value <0.001) between PCT serum levels, CRP (r = 0.662)
and WBC count (r = o.591). Also, we found a highly statisti-
cally negative correlation (p < 0.05) between PCT serum levels
and FEV1 (r = 0.625).
Discussion
In our study, there was a highly statistically significant differ-
ence (p value <0.001) between AECOPD patients on one side
and stable COPD patients and healthy control subjects on the
other side regarding the mean values of PCT (1.44 ±
0.542 ng/ml among AECOPD patients, 0.05 ± 0.012 ng/ml
among stable COPD patients, 0.04 ± 010 ng/ml among
healthy control subjects). Other investigators found similar
results. In a study by Tasci et al. [19] the mean serum PCT
levels in COPD patients with exacerbations were 1.8 ng/ml
and in stable COPD patients was 0.2 ng/ml. A significant cor-
relation was established between serum procalcitonin (PCT)

Table 1 Some characteristic data for the subjects included in this study.
Exacerbated COPD (N = 30) Stable COPD (N = 23) Healthy Subjects (N = 20)
Age (Mean ± SD) 60.52 ± 11.07 58.60 ± 10.44 58.35 ± 9.25
Sex (Male/Female) 21/9 15/8 13/7
FEV1% 50.42 ± 19.5 55.98 ± 22.15 105 ± 9.22
FVC% 55.80 ± 17.9 60 ± 20.62 98 ± 11.50
FEV1/FVC% 55.3 ± 8.4 59.3 ± 7.8 90 ± 7.83
CRP (mg/L) 66.03 ± 22.85 6.43 ± 1.60 5.98 ± 1.44
WBC (·103/lL) 13.94 ± 4.20 7.6 ± 2.45 6.5 ± 2.74
PO2 59.3 ± 14.7 63.51 ± 16.22 95.68 ± 2.9
PCO2 42.2 ± 11.5 40.01 ± 8.50 39.50 ± 2.66
Smoking history
Current 8 6 0
Ex smoker 20 14 0
Non smoker 2 3 20
Severity of COPD by GOLD criteria
I (FEV1 P 80% of predicted) 4 (13.33%) 5 (21.73%) –
I I (FEV1 P 50% & < 80%) 7 (23.33%) 8 (34.78%) –
I I I (FEV1 P 30% & < 50%) 11 (36.67%) 7 (30.43%) –
IV(FEV1 < 30% of predicted) 8 (26.67%) 3 (13.04%) –

Please cite this article in press as: A.A. El Halim, M. Sayed, The value of serum procalcitonin among exacerbated COPD patients, Egypt. J. Chest Dis. Tuberc. (2015),
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
4 A.A. El Halim, M. Sayed

Figure 1 Comparison between different subject groups regarding PCT levels (ng/ml).

significantly higher than COPD in stable conditions. In a study

Table 3 Microbiological profile among AECOPD patients.
by Zhang Y and his colleague [22], before treatment, the levels
Bacteria type Microbes AECOPD patients no. of CRP, PCT, WBC, and N in the infective COPD group were
(%) significantly higher than that in the non-infective group
Gram +ve Streptococcus 7 (23.33%) (p < 0.05 or p < 0.01), while there was no significant differ-
(23.33%) pneumoniae ence in ESR level between the 2 groups (p > 0.05). In the
Gram ve Haemophilus 9 (30%) infective group, the levels of CRP, PCT, WBC, N and ESR
(66.33%) influenzae after the treatment were much lower than those before treat-
Pseudomonas 7 (23.33%) ment (p < 0.05). After treatment, the levels of CRP, PCT,
aeruginosa
WBC, and neutrophils in the infective group were significantly
Moraxella catarrhalis 3 (10%)
Atypical Mycoplasma 2 (6.67%)
(13.34%) pneumoniae
Chlamydia 2 (6.67%)
pneumoniae

Table 4 Comparison between different bacteria regarding

PCT levels (ng/ml).
Microbes PCT (ng/ml) p Value
Mean ± SD
*
Pseudomonas 1.976 ± 0.623 VS**
aeruginosa* p < 0.05
Streptococcus 1.245 ± 0.416
pneumoniae**
Haemophilus influenzae** 1.198 ± 0.238
Moraxella catarrhalis** 1.166 ± 0.305
Mycoplasma 1.150 ± 0.071
pneumoniae**
Chlamydia pneumoniae** 1.250 ± .353

levels and duration of hospital stay, ESR and sputum puru-

lence (p = 0.002, p = 0.007 respectively). Mohamed and his
colleagues [20] found the levels of PCT for patients of group
A (bacterial exacerbated COPD) (2.69 ± 0.62 ng/ml) were sig-
nificantly higher than group B (non bacterial exacerbated
COPD) (0.07 ± 0.02 ng/ml) and control group (0.05 ±
0.02 ng/ml) (p < 0.001). Pazarli et al. [21] analyzed PCT levels
among two selected COPD groups, AECOPD (the case group)
compared to stable COPD as a control group. This study dis- Figure 2 ROC curve for PCT serum levels among AECOPD
covered that mean levels of PCT in AECOPD were patients infected with Pseudomonas aeruginosa.

Please cite this article in press as: A.A. El Halim, M. Sayed, The value of serum procalcitonin among exacerbated COPD patients, Egypt. J. Chest Dis. Tuberc. (2015),
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
Value of serum procalcitonin among exacerbated COPD patients
Table 5 Comparison between mechanically ventilated and
non-mechanically ventilated AECOPD patients regarding PCT
serum levels (ng/ml).
COPD patients PCT
(Mean ± SD)
Mechanically ventilated (No = 7) 2.024 ± 0.564
Non mechanically ventilated 1.262 ± 0.399
(No = 23)
higher compared with that in the non-infective group
(p < 0.05), while there was no significant difference of ESR
level between the 2 groups (p > 0.05). There was a positive
relationship between PCT and CRP, ESR and WBC
(r = 0.46, 0.38, 0.20; p < 0.05), CRP and WBC as well as N
and ESR (r = 0.56, 0.43, 0.30; p < 0.05). Tanrıverdi et al.
[23] found that the mean PCT levels were significantly higher
in COPD patients with positive sputum cultures than in
patients with negative sputum cultures. The cut-off values
for PCT, CRP, and the neutrophils/lymphocytes (N/L) ratio
for predicting a bacterial infection were 0.40 ng/mL,
91.50 mg/L, and 11.5, respectively; sensitivity was 61, 54, and
61% respectively; specificity was 67, 52, and 58%, respectively;
and the area under the curve (AUC) values were 0.64, 0.52,
and 0.58, respectively. The AUC value of PCT was signifi-
cantly better for predicting bacterial infection compared with
the CRP level or the N/L ratio (p = 0.042). The investigations
identified PCT as part of the complex pro-inflammatory
response of the innate immune system. In vitro stimulation
of macrophages with either bacteria or endotoxin results in
rapid synthesis and release of tumor necrosis factor, (TNF),
interleukin (IL) -1, and IL-6 [4]. Within 4 h, the synthesis of
PCT is detectable. PCT differs from other biomarkers of the
invasion by bacterial pathogens. Serum PCT serum levels are
detectable as early as 3–4 h after the invasion, which is much
earlier than the increase in the C-reactive protein level or ery-
throcyte sedimentation rate [5,6].
In this study, we found Gram negative bacteria caused
COPD exacerbation in 66.33% of the patients, Gram positive
bacteria in 23.33% of them and atypical bacteria in 13.34% of
Figure 3 Comparison between mechanically ventilated and non-mechanically ventilated AECOPD patients regarding PCT serum levels
(ng/ml).
Please cite this article in press as: A.A. El Halim, M. Sayed, The value of serum procalcitonin among exacerbated COPD patients, Egypt. J. Chest Dis. Tuberc. (2015),
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
5
the patients. H. influenzae (30%) was the most common organ-
ism followed by S. pneumoniae (23.33%), P. aeruginosa
(23.33%), M. catarrhalis (10%), M. pneumoniae (6.67% and
C. pneumoniae (6.67%). Similar results detected by the others.
p Value In a study by Soler et al. [18] the microbial patterns among
COPD exacerbation corresponded to community-acquired
p < 0.001 pathogens (S. pneumoniae, H. influenzae, and moraxella catar-
rhalis) in 19 of 34 (56%) and to Gram-negative enteric bacilli
(GNEB), pseudomonas, and Stenotrophomonas spp. in 15 of
34 (44%) of isolates. C. pneumoniae and respiratory viruses
were found in 18% and 16% of investigations, respectively.
Ko and his group [24] found among sputum samples from
the 530 episodes of AECOPD hospital admissions, a positive
growth of H. influenzae, P. aeruginosa, and S. pneumoniae.
In a study by Nakou et al. [25] conducted on the exacerbated
COPD patients, the most common bacteria were H. influenzae
and P. aeruginosa (23.9 and 14.1%, respectively).
Acinetobacter baumannii- and P. aeruginosa-positive cultures
were associated with prolonged hospitalization and severe air-
way obstruction (p = 0.03 and 0.031, respectively). C. pneumo-
niae or M. pneumoniae infection was diagnosed in four and two
patients, respectively.
This study found a statistical significant difference (p value
<0.05) between AECOPD patients infected with P. aeruginosa
and AECOPD patients infected with other bacteria regarding
the mean serum levels of PCT. The cutoff value of 1.215 ng/ml
PCT serum level has 66.7% sensitivity and 100% specificity for
P. aeruginosa. The area under the curve was 0.836. Our find-
ings agree with other investigators. Daubin and his group
[26] detected high PCT serum levels among COPD patients
with P. aeruginosa. These results are expected due to the viru-
lence of P. aeruginosa and the associated exuberant inflamma-
tory reactions.
A statistically significant difference (p value <0.001) was
present among AECOPD patients that needed ventilatory sup-
port and those did not need, At cutoff 1.495 ng/ml, PCT had
85.7% sensitivity and 78.3% specificity for predicting
AECOPD patients that needed ventilatory support. The area
under the curve was 0.891. Other researchers discovered simi-
lar results. Rammaert et al. [27] revealed that higher PCT levels
in severe AECOPD cases were associated with the necessity of
mechanical ventilation and intensive care unit mortality. In the
6 A.A. El Halim, M. Sayed
Figure 4 ROC curve for PCT serum levels among AECOPD
patients that mechanically ventilated.
same study they reported high mortality rate in cases whose
PCT levels were higher than 0.24 ng/ml. In a study by
Pazarli et al. [21] the mean PCT levels increased, especially
in cases with severe AECOPD and those receiving NPPV
among them. They determined a cutoff value of PCT as
0.10 ng/ml as a predictor of the necessity of non invasive
positive pressure ventilation (NPPV) in AECOPD.
We detected a highly statistically positive correlation (p
value <0.001) between PCT serum levels, CRP (r = 0.662)
and WBC count (r = 0.591). Also, we found a highly statisti-
cally negative correlation (p < 0.05) between PCT serum levels
and FEV1 (r = 0.625). These results agreed with that of
other studies. Pazarli and his colleagues [21] detected a signif-
icant positive correlation between PCT levels during COPD
exacerbation, and CRP, ESR, WBC and neutrophil counts.
Also, Daniels et al. [28] reported positive correlation between
PCT and CRP. Mohamed et al. [20] found that PCT has a sig-
nificant correlation with both ESR, CRP, leucocytes count and
body temperature. Also in this study, a high PCT pointed to
increasing severity of AECOPD. Daubin et al. [26] reported
PCT levels of >0.25 l/L in patients with very severe COPD.
Rammaert et al. [27] revealed that higher PCT levels in severe
AECOPD cases were associated with the necessity of mechan-
ical ventilation and intensive care unit mortality.
Conclusions
This study found increased PCT serum levels among
AECOPD patients and suggests a role for PCT in the predict-
ing of bacterial infections and their needs for ventilatory sup-
port. We recommend other large studies to augment our
findings.
Please cite this article in press as: A.A. El Halim, M. Sayed, The value of serum procalcitonin among exacerbated COPD patients, Egypt. J. Chest Dis. Tuberc. (2015),
http://dx.doi.org/10.1016/j.ejcdt.2015.05.016
Conflict of interest
We have no conflict of interest to declare.
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