Clinical review: the role of biomarkers in the diagnosis and management of community-acquired pneumonia

Abstract

In patients with community-acquired pneumonia, traditional criteria of infection based on clinical signs and symptoms, clinical scoring systems, and general inflammatory indicators (for example, leukocytosis, fever, C-reactive protein and blood cultures) are often of limited clinical value and remain an unreliable guide to etiology, optimal therapy and prognosis. Procalcitonin is superior to other commonly used markers in its specificity for bacterial infection (allowing alternative diagnoses to be excluded), as an indicator of disease severity and risk of death, and mainly as a guide to the necessity for antibiotic therapy. It can therefore be viewed as a diagnostic, prognostic, and perhaps even theragnostic test. It more closely matches the criteria for usefulness than other candidate biomarkers such as C-reactive protein, which is rather a nonspecific marker of acute phase inflammation, and proinflammatory cytokines such as plasma IL-6 levels that are highly variable, cumbersome to measure, and lack specificity for systemic infection. Elevated levels of pro-adrenomedullin, copeptin (which is produced in equimolar amounts to vasopressin), natriuretic peptides and cortisol are significantly related to mortality in community-acquired pneumonia, as are other prohormones such as pro-atrial natriuretic peptide, coagulation markers, and other combinations of inflammatory cytokine profiles. However, all biomarkers have weaknesses as well as strengths. None should be used on its own; and none is anything more than an aid in the exercise of clinical judgment based upon a synthesis of available clinical, physiologic and laboratory features in each patient.

Figure 1

Diagnostic accuracy of different biomarkers for community-acquired pneumonia. Receiver operating characteristics (ROC) curves for diagnostic accuracy to predict radiographically suspected community-acquired pneumonia (CAP) including other non-infectious diagnoses initially diagnosed as CAP plus patients without a clinically relevant bacterial etiology of CAP. Values show areas under the ROC curve with 95% confidence intervals. CRP, C-reactive protein; PCT, procalcitonin.

Figure 2

Algorithm for antibiotic therapy in patients with lower respiratory tract infections. Clinical algorithm for the diagnostic workup and guidance of antibiotic therapy in patients with lower respiratory tract infections (LRTI). ARDS, acute respiratory distress syndrome; CAP, community-acquired pneumonia; COPD, chronic obstructive pulmonary disease; CURB, Confusion, Urea, Respiratory rate, Blood pressure; GOLD, Global Initiative for chronic destructive Lung Disease; ICU, intensive care unit; PSI, pneumonia severity index.