Are admission procalcitonin levels universal mortality predictors across different medical emergency patient populations? Results from the multi-national, prospective, observational TRIAGE study

Ramon Sager; Yannick Wirz; Devendra Amin; Adina Amin; Pierre Hausfater; Andreas Huber; Sebastian Haubitz; Alexander Kutz; Beat Mueller; Philipp Schuetz

doi:10.1515/cclm-2017-0144

Article

Are admission procalcitonin levels universal mortality predictors across different medical emergency patient populations? Results from the multi-national, prospective, observational TRIAGE study

Ramon Sager , Yannick Wirz , Devendra Amin , Adina Amin , Pierre Hausfater , Andreas Huber , Sebastian Haubitz , Alexander Kutz , Beat Mueller and Philipp Schuetz

Published/Copyright: April 17, 2017

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From the journal Clinical Chemistry and Laboratory Medicine (CCLM) Volume 55 Issue 12

Abstract

Background:

Procalcitonin (PCT), an inflammatory blood biomarker, is well studied in infectious diseases. Its prognostic value in unselected emergency department (ED) patients remains yet undefined. Herein, we investigated association of admission PCT levels and mortality in a large, international-multicenter ED patient cohort.

Methods:

We prospectively enrolled 6970 unselected, consecutive, adult, medical patients seeking ED care in three tertiary-care hospitals in Switzerland, France and the USA. We used multivariable logistic regression models to examine association of admission PCT levels (as a continuous predictor and across cut-offs) and 30-day mortality. We also investigated subgroup effects by main diagnosis, comorbidities and clinical features at presentation.

Results:

During the 30-day follow-up, 328 (4.7%) participants died. Mortality increased stepwise within higher PCT cut-offs (0.05, 0.1, 0.25, 0.5 ng/mL) from 1%, 3%, 7%, 13% to 15%, respectively. This association was also confirmed in a fully-adjusted model including age, gender, main symptom, main diagnosis and vital parameters on admission. Receiver operating characteristic (ROC) curve analysis showed that PCT differentiated well between survivors and non-survivors in the overall cohort (area under ROC curve [AUC] 0.75) with best results for patient with metabolic (AUC: 0.85) and cardiovascular disease (AUC: 0.82). Addition of PCT also improved the prognostic accuracy of the quick sequential organ failure assessment (qSOFA) score from an AUC of from 0.61 to 0.76 (p<0.001). Results were similar for other secondary endpoints including intensive care unit (ICU) admission and hospital readmission.

Conclusions:

In this large and heterogenous medical ED patient cohort, admission PCT was a strong and independent outcome predictor for 30-day mortality across different medical diagnoses independent of underlying infection. PCT may help to improve risk stratification in unselected medical ED patients.

Keywords: emergency department; outcome; procalcitonin; risk stratification

Corresponding author: Prof. Philipp Schuetz, MD, MPH, Medical Faculty, University of Basel, Switzerland

Acknowledgments

This multi-disciplinary and inter-professional trial was only possible in close collaboration of social services (Anja Keller, Regina Schmid), the nursing department (Susanne Schirlo, Petra Tobias), the central laboratory (Martha Kaeslin, Renate Hunziker), medical controlling (Juergen Froehlich, Thomas Holler, Christoph Reemts), IT (Roger Wohler, Kurt Amstad, Ralph Dahnke, Sabine Storost) of the Kantonsspital Aarau, Clinical Trial Unit (CTU), University Hospital Basel (Thomas Fabbro, Guido Stirnimann, Patrick Simon), the department of Health Economics of the University of Basel (Stefan Felder, Timo Tondelli), as well as all participating patients, nurses and physicians.

Author contributions: All authors made substantive intellectual contributions to this study with regard to conception, design, have taken an active part in acquisition, analysis and interpretation of data. R.S. and P.S. conducted statistical analyses and drafted the first manuscript. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: Thermofisher provided an unrestricted research grant for the TRIAGE study. P.S. and B.M. are supported by the Swiss National Science Foundation (SNSF Professorship, PP00P3_150531/1 and SNSF Grant “InHospiTOOL” NRP 74 407440_167376, respectively).
Employment or leadership: None declared.
Honorarium: A.K., P.S. and B.M. received support from B·R·A·H·M·S AG (now ThermoFisher Scientific Biomarkers) and bioMérieux for meetings, speaking engagements, and research grants. B.M. has served as a consultant to both companies. P.H. received research grants from ThermoFisher Scientific BRAHMS to attend meetings and fulfil speaking engagements. All other authors have no conflicts of interest relevant to this paper.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

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Supplemental Material:

The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2017-0144).

Received: 2017-2-20

Accepted: 2017-3-20

Published Online: 2017-4-17

Published in Print: 2017-10-26

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Keywords for this article

emergency department; outcome; procalcitonin; risk stratification

Are admission procalcitonin levels universal mortality predictors across different medical emergency patient populations? Results from the multi-national, prospective, observational TRIAGE study

Article

Abstract

Background:

Methods:

Results:

Conclusions:

Acknowledgments

References

Supplemental Material:

Supplementary Material

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