降钙素原在诊断社区获得性肺炎和指导抗生素应用中的价值

目的：探讨降钙素原（PCT）在诊断社区获得性肺炎（CAP）和指导抗生素应用中的价值。方法：回顾性分析2013年5月至2014年5月收住我院呼吸科的CAP患者296例,同期收住的其他患者221例,比较PCT在CAP和非CAP患者之间、老年和非老年CAP之间的差异,作ROC曲线,运用最大约登指数法确定PCT诊断CAP的最佳临界值及相应的灵敏度（SEN）和特异度（SPE）。结果：CAP患者PCT显著高于非CAP患者（P＜0．05）。 PCT诊断CAP的ROC曲线下面积（AUC）是0．67,最佳临界值是0．055 ng／mL,对应的SEN和SPE分别是0．55和0．77。老年CAP患者PCT水平低于非老年CAP患者。 PCT诊断老年CAP的AUC是0．63,最佳临界值是0．55 ng／mL,对应的SEN和SPE分别是0．53和0．73。 PCT诊断非老年CAP的AUC是0．73,最佳临界值是0．085 ng／mL,对应的SEN和SPE分别是0．53和0．90。 PCT指导抗生素应用与临床结合影像学指导抗生素应用比较疗程更短（P＜0．05）,而疾病复发率无差异（P＞0．05）。结论：PCT在诊断CAP和指导抗生素应用中具有较高价值。     

社区获得性肺炎严重程度及危险评价研究进展

目前社区获得性肺炎(community acquired pneumonia,CAP)的病死率和病原体的耐药率仍很高,并且在CAP的诊断和严重程度及危险评价上还面临许多新的问题[1],现就CAP的诊断标准、国内外现状、病情严重程度评估和危险分层等方面综述如下.     

社区获得性小儿支气管肺炎肺炎链球菌药物敏感分析

目的探讨儿童社区获得性支气管肺炎肺炎链球菌感染情况及其耐药性。方法 4 208例确诊的支气管肺炎患儿,经鼻插入无菌吸痰管8~15cm,采用负压吸引器吸取呼吸道深部分泌物进行细菌培养,并对分离株进行鉴定及药物敏感试验。结果培养肺炎链球菌157株;喹诺酮类敏感率大于95.0%;注射青霉素敏感率为92.4%;碳青霉烯类敏感率90.4%;大环内酯类耐药率大于75.0%;复方磺胺甲噁唑耐药达60.9%;脑膜炎、非脑膜炎型肺炎链球菌耐青霉素达30.1%以上。结论抗菌药物的广泛应用,小儿肺炎链球菌的耐药菌株增多,治疗难度增大,合理选用抗菌药物是减少耐药性产生的重要措施。     

社区获得性肺炎合并低蛋白血症的调查及危险因素分析

目的:探讨社区获得性肺炎(CAP)合并低蛋白血症的危险因素及预防措施。方法:选取2018-07—2018-10期间以CAP为首要诊断在首都医科大学附属北京朝阳医院急诊留观住院的患者,记录患者性别、年龄、合并疾病,入院时体质指数(BMI)、胃肠损伤分级(AGI)、胸腔积液、尿蛋白、血清白蛋白(ALB)、血清前白蛋白(PAB)、血红蛋白(HGB)、白细胞计数(WBC)、氧分压(PaO_2)、二氧化碳分压(PaCO_2)、治疗期间的ALB、PAB,出院后记录患者使用抗菌药物的种类及住院天数。分析以上指标与社区获得性肺炎合并低蛋白血症的相关性。结果:共87例CAP患者,入院时合并低蛋白血症的占56.3%(49/87)。入院时,合并低蛋白血症组与未合并低蛋白血症组患者的胃肠损伤分级、胸腔积液、尿蛋白情况比较均差异有统计学意义(P0.05)。住院期间,年龄≥70岁的患者新发低蛋白血症的比例明显高于年龄70岁的患者(分别为61.3%,14.3%),差异有统计学意义(P0.05)。合并慢性疾病种类越多的患者合并低蛋白血症的发生率越高,合并低蛋白血症的患者使用抗生素的品种数增加、住院时间延长,均差异有统计学意义(P0.05)。结论:CAP合并低蛋白血症的危险因素包括胃肠功能损伤、胸腔积液、尿蛋白阳性等,积极处理相关危险因素有利于有效防治低蛋白血症,以减少抗生素的使用及缩短患者的住院时间。     

中国社区获得性肺炎病情评估标准与肺炎严重指数的效能比较

目的比较中国社区获得性肺炎(CAP)病情评估标准(简称我国标准)与国外现行肺炎严重指数(PSI)评估标准对CAP患者病情严重程度和预后判断的有效性。方法选取2010年6月至2012年1月我院呼吸科就诊的CAP患者155例作为研究对象,通过回顾性分析,将患者分别按我国标准和PSI评分标准划分为低、中、高危组,比较各组重症监护病房(ICU)住院率和死亡率,从而评估各系统预测ICU住院和死亡的敏感度、特异度、总体准确率和两者ROC曲线下面积。结果 PSI评分标准将较大一部分患者划分为低危组(74.2%),较小部分患者划为中危组和高危组(14.8%和11%)。低危组和中危组均有死亡病例(病死率分别为1.7%和11.4%)。我国标准仅将较小部分患者划为低危组(34.2%),将较大部分患者划为中危组和高危组(38.7%和27.1%),低危组和中危组病死率分别为0和5%,中危组ICU住院率也仅为6.7%。PSI(Ⅳ)预测入住ICU及死亡的特异度均较高(95.5%和92.3%),而敏感度均较低(预测入住ICU47.8%,预测死亡为50%);我国标准(重症肺炎)预测入住ICU及死亡的敏感度高(82.6%和75%),而特异度较低(82.6%和76.9%)。PSI(Ⅳ)对于入住ICU及死亡的总体预测准确率优于我国标准(88.4%vs.82.6%;89%vs.76.8%)。PSI对于入住ICU及死亡预测的ROC曲线下面积与我国标准接近(0.875vs.0.861;0.832vs.0.806)。结论在筛选低风险CAP患者、入住ICU和预测死亡方面,PSI和CURB65评分标准和我国标准各有优势与不足,各医疗单位应根据各自实际情况对患者病情进行评估。     

109株阴沟肠杆菌的耐药性分析

目的：分析阴沟肠杆菌（Ｅｎｔｅｒｏｂａｃｔｒ ｃｌｏａｃａｅ）耐药现状,指导临床合理用药。方法：对北京协和医院１９９７年一年间从临床分离的１０９株阴沟肠杆菌采用纸片扩散法进行了药敏试验,并用“ＷＨＯＮＥＴ４”软件对试验数据分析处理。结果：阴沟肠杆菌对β－内酰胺类抗生素多重耐药,尤其对氨苄西林、头孢美唑及头孢唑啉的耐药率很高,均在７９．８％以上,对其他第二、第三代头孢菌素也有２２．０％～４８．６％。     

儿童社区获得性肺炎（CAP）病原构成及肺炎链球菌耐药性分析

目的研究儿童社区获得性肺炎（CAP）的病原构成,并观察肺炎链球菌对临床常用抗生素的耐药性。方法对2010年1月-2012年2月于我院儿科就诊的60例社区获得性细菌性肺炎（CAP）患儿采取呼吸道深部吸取痰液并行痰培养,对检测出的菌株进行分离统计,并观察检出菌株最多的肺炎链球菌对临床常用抗生素的耐药性。结果60例CAP患儿痰标本培养菌株69株,致病菌分布前5住的分别是：肺炎链球茵（SP）,占比26．1％;肺炎克雷伯菌（KNP）,占比18．8％;大肠杆菌（E．coli）,占比15．9％;流感嗜血杆菌（Hib）,占比13．O％;金黄色葡萄球菌（Staphylococcus aureus）,占比8．7％。在肺炎链球菌对常用抗生素的耐药性方面,亚胺培南未检出耐药茼株,头孢哌酮／舒巴坦、左氧氟沙星、哌拉西林等耐药性较低,庆大霉素、四环素、红霉素耐药性较高。结论肺炎链球菌（SP）在儿童社区获得性肺炎中属于常见致病菌株,对儿童CAP的治疗应重视痰培养并以此为依据选择敏感抗生素进行治疗。     

莫西沙星序贯治疗社区获得性肺炎住院患者疗效观察

目的 评价莫西沙星序贯治疗社区获得性肺炎(CAP)住院患者的疗效和安全性.方法 北京大学深圳医院2009年1月-2010年12月收治的186例CAP住院患者随机分为2组,莫西沙星序贯组(序贯组)和莫西沙星静脉滴注组(对照组),序贯组(86例)在治疗当天开始给予莫西沙星注射液400 mg/d静脉滴注,每日1次,3～5d后改为口服莫西沙星片剂400 mg/d,总疗程7～14 d;对照组(88例)给予莫西沙星注射液400 mg/d静脉滴注,每日1次,总疗程7～14 d.结果 经剔除部分患者后,两组均无严重不良反应,两组安全性比较差异无统计意义,临床疗效:序贯组有效率87.2%,对照组有效率89.8%.细菌学疗效比较:治疗后序贯组细菌清除率为92.1%,对照组细菌清除率为95.7%,两组差异无统计学意义(P>0.05).结论 莫西沙星对住院CAP患者疗效可靠,安全性好.序贯治疗组与全程静脉滴注相仿,对于可以口服的患者可以替代全程静脉滴注作为住院CAP患者的治疗方案.     

多个评估系统对社区获得性肺炎严重度评估的荟萃分析

目的: 通过分析已有的临床数据,观察多个评估系统对社区获得性肺炎（community acquired pneumonia,CAP）患者30 d的死亡风险和ICU入住风险的预测价值。方法: 用关键词途径对2004年至2015年的PubMed和EMBASE数据库进行文献检索,并对符合条件的所有研究进行荟萃分析。结果: 共纳入文献48篇,共51 639例CAP患者采用各评价系统对其30 d死亡风险进行评估,共评估了10 590例CAP患者入住ICU的风险。通过汇总计算得出,对于30 d死亡风险的预测,CRB-65（confusion,respiratory,age 65 years）评分系统的灵敏度为98%,特异度为33%,综合受试者工作特征（summary receiver operating characteristic,sROC）曲线下面积为0.56;英国胸科协会改良肺炎评分(confusion, uremia, respiratory,blood pressure, age 65 years, CURB-65评分)系统的灵敏度为84%,特异度为55%,sROC曲线下面积为0.78;肺炎严重度指数(pneumonia severity index, PSI)系统的灵敏度为90%,特异度为57%,sROC曲线下面积为0.88;以符合2007美国感染病学会(Infectious Diseases Society of America,IDSA) /美国胸科学会（American Thoracic Society, ATS) 3项以上次要标准且不符合主要标准的评估灵敏度为76%,特异度为90%,sROC曲线下面积为0.89;采用SMART-COP评估的灵敏度为77%,特异度为65%,sROC曲线下面积为0.67。对于入住ICU风险,采用CURB-65系统评估的灵敏度为52%,特异度为77%,sROC曲线下面积为0.67;采用PSI系统评估的灵敏度为70%,特异度为61%,sROC曲线下面积为0.69;采用SMART-COP评分评估的 灵敏度为84%,特异度为70%,sROC曲线下面积为0.74。结论: PSI、CURB-65评分系统对患者30 d死亡风险的预测价值较大,可作为住院标准的重要参考。对于收住ICU的风险评估,SMART-COP的预测价值相对较大,而PSI、CURB-65评分价值相对较低。     

Serial quantification of procalcitonin (PCT) predicts clinical outcome and prognosis in patients with community-acquired pneumonia (CAP)

Procalcitonin (PCT), a calcitonin precursor, is commonly measured in the setting of community-acquired pneumonia (CAP). However, the clinical significance of serial PCT changes has not been established. We conducted a prospective observational study of 122 patients with CAP. Thirty-day mortality was the primary endpoint. Secondary endpoints included: (1) initial treatment failure, (2) 30-day mortality and/or initial treatment failure, and (3) intensive care unit (ICU) admission. In subgroup analysis, we classified patients into pneumococcal pneumonia and non-pneumococcal pneumonia groups. The baseline frequency of 30-day mortality was 10.7%. Increases in serum PCT levels from admission to Day 3 were observed with statistically higher frequency in patients with 30-day mortality (P = 0.002). For secondary endpoints, only the 30-day mortality and/or initial treatment failure group was statistically significant (P = 0.007). Subgroup analysis revealed statistically significant changes in the non-pneumococcal pneumonia group (N = 85) across several endpoints, including 30-day mortality (P = 0.001), initial treatment failure (P = 0.013), and 30-day mortality and/or initial treatment failure (P < 0.001). No significant changes in endpoint measurements were found in the pneumococcal pneumonia group (N = 28). Interestingly, serum PCT levels at the time of diagnosis were higher in patients with pneumococcal pneumonia than those with non-pneumococcal pneumonia (P = 0.006), and this positively correlated with disease severity scores for all patients (PCT vs. PSI: R = 0.380, P < 0.001; PCT vs. A-DROP: R = 0.422, P < 0.001) and for non-pneumococcal pneumonia (PCT vs. PSI: R = 0.468, P < 0.001; PCT vs. A-DROP: R = 0.448, P < 0.001), but not for pneumococcal pneumonia. In conclusion, serial quantification of PCT can predict clinical outcomes for patients with CAP.     

A prospective comparison of nursing- and healthcare-associated pneumonia (NHCAP) with community-acquired pneumonia (CAP)

Nursing- and healthcare-associated pneumonia (NHCAP) has been proposed by the Japanese Respiratory Society as a new category of pneumonia considering the characteristics of the Japanese medical care environment. It is necessary to ascertain the epidemiology and clinical outcomes of NHCAP. A prospective study was conducted of patients with pneumonia who were hospitalized at our hospital from August 2011 to July 2012. We compared 192 cases of NHCAP with 114 cases of community-acquired pneumonia (CAP). Compared with CAP, NHCAP had a higher disease severity, higher 30-day mortality rate (10.9 vs. 3.5 %, P = 0.022), and longer length of hospital stay (median, 12 vs. 8 days, P < 0.001). Streptococcus pneumoniae was the most frequent causative pathogen in both NHCAP and CAP (33.9 vs. 34.8 %, P = 0.896). The incidence of atypical pathogens in NHCAP was low (1.7 %). Multidrug-resistant (MDR) pathogens were isolated more frequently in NHCAP than in CAP, but there was no significant difference (11.0 vs. 4.5 %, P = 0.135). Among 192 NHCAP patients, 122 (63.5 %) were aspiration pneumonia. Aspiration pneumonia was associated with poor outcomes and was considered a major characteristic of NHCAP. Our study suggested that many patients with NHCAP do not need broad-spectrum antibiotic therapy targeting MDR pathogens. Excess mortality in NHCAP patients is the result of patient backgrounds or disease severity rather than the presence of MDR pathogens.     

社区获得性肺炎初始治疗失败的评估与处理进展

社区获得性肺炎(community-acquired pneumonia,CAP)具有高发病率和高病死率的特点,危害严重。CAP初始治疗的成败很大程度上决定着患者疾病转归。在确立CAP临床诊断并安排合理病原学检查及标本采样后,需根据患者年龄、基础疾病、临床特点等分析患者病原学特征,及时实施初始经验性抗感染治疗。虽然我国和世界众多国家都制定了CAP诊疗指南,但CAP的初始治疗失败率高仍是不可回避的问题。本文对CAP初始治疗失败的评估与处理进展进行综述,以期为CAP的临床诊治提供帮助。     

Circulating cytokines as markers of systemic inflammatory response in severe community-acquired pneumonia

OBJECTIVES: To assess the influence of empirical antibacterial therapy on systemic inflammatory response in patients with severe community-acquired pneumonia (CAP). MATERIAL AND METHODS: Thirty consecutive patients with CAP meeting systemic inflammatory response syndrome (SIRS) criteria were recruited into this study. Blood samples for measurement of interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10) and C-reactive protein (CRP) concentrations were drawn on days 1, 3, 5, 7 and 10. For analysis, these patients were divided into two subgroups according to British Thoracic Society (BTS) severity score and to clinical response to the initial antibacterial therapy. RESULTS: In the group with severe CAP (n= 15), serum concentrations of IL-6 (P = 0.0001), IL-8, (P = 0.001), IL-10 (P = 0.0001) and CRP (P = 0.0001) were significantly higher compared to patients from the non-severe group (n= 15). IL-6 presented with a sharp decrease between days 1 and 3 in non-responders with severe CAP (P = 0.004). IL-6 concentrations on day 1 were significantly associated with a response to empirical antibacterial treatment by day 3. CONCLUSION: Despite the absence of a clinical response to empirical antibacterial treatment as assessed by conventional clinical parameters on day 3 in patients with severe CAP meeting SIRS criteria, there was a marked reduction in the degree of the systemic inflammatory response as reflected by IL-6 levels.     

Procalcitonin kinetics in the prognosis of severe community-acquired pneumonia

Objectives Procalcitonin (PCT) kinetics is a good prognosis marker in infectious diseases, but few studies of community-acquired pneumonia (CAP) have been performed in intensive care units (ICU). We analyzed the relationship between PCT kinetics and outcome in ICU patients with severe CAP. Design and setting Prospective observational study in a 16-bed university hospital ICU. Patients 100 critically ill patients with community-acquired pneumonia. Measurements and results Median PCT was 5.2 ng/ml on day 1 and 2.9 ng/ml on day 3. It increased from day 1 to day 3 in nonsurvivors but decreased in survivors. In multivariate analysis four variables were associated with death: invasive ventilation (odds ratio 10−), multilobar involvement (5.6−), LOD score (6.9−), and PCT increase from day 1 to day 3 (4.5−). In intubated patients with a PCT level below 0.95 ng/ml on day 3 the survival rate was 95%. Conclusion Increased PCT from day 1 to day 3 in severe CAP is a poor prognosis factor. A PCT level less than 0.95 ng/ml on day 3 in intubated patients is associated with a favorable outcome. Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Antibiotic susceptibility in relation to genotype of Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae responsible for community-acquired pneumonia in children

Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae are the main pathogens causing community-acquired pneumonia (CAP). We identified S. pneumoniae (n = 241), H. influenzae (n = 123), and M. pneumoniae (n = 54) as causative pathogens from clinical findings and blood tests from pediatric CAP patients (n = 903) between April 2008 and April 2009. Identification of genes mediating antimicrobial resistance by real-time PCR was performed for all isolates of these three pathogens, as was antibiotic susceptibility testing using an agar dilution method or broth microdilution method. The genotypic (g) resistance rate was 47.7 % for penicillin-resistant S. pneumoniae (gPRSP) possessing abnormal pbp1a, pbp2x, and pbp2b genes, 62.6 % for β-lactamase-nonproducing, ampicillin-resistant (gBLNAR) H. influenzae possessing the amino acid substitutions Ser385Thr and Asn526Lys, and 44.4 % for macrolide-resistant M. pneumoniae (gMRMP) possessing a mutation of A2063G, A2064G, or C2617A. Serotype 6B (20.3 %) predominated in S. pneumoniae, followed by 19F (15.4 %), 14 (14.5 %), 23F (12.0 %), 19A (6.2 %), and 6C (5.4 %). Coverage for the isolates by heptavalent pneumococcal conjugate vaccine (PCV7) and PCV13, respectively, was calculated as 68.5 and 80.9 %. A small number of H. influenzae were identified as type b (6.5 %), type e (0.8 %), or type f (0.8 %); all others were nontypeable. Proper use of antibiotics based on information about resistance in CAP pathogens is required to control rapid increases in resistance. Epidemiological surveillance of pediatric patients also is needed to assess the effectiveness of PCV7 and Hib vaccines after their introduction in Japan.     

A retrospective study of health care-associated pneumonia patients at Aichi Medical University hospital

Health care-associated pneumonia (HCAP) was defined in the American Thoracic Society/Infectious Disease Society of America guidelines on hospital-acquired pneumonia in 2005. However, little is known about the occurrence of HCAP in Japan. A retrospective review of background characteristics, pathological conditions, causative organisms, initial treatments, and risk factors for HCAP was conducted to determine the relationship of HCAP to community-acquired pneumonia and hospital-acquired pneumonia. Thirty-five patients who were admitted to our hospital for pneumonia acquired outside our hospital were included and were stratified by disease severity according to the Japanese Respiratory Society risk stratification guidelines (A-DROP [age, dehydration, respiratory failure, orientation disturbance, and shock blood pressure] criteria). All patients had an underlying disease. A total of 70 microbial strains (25 gram-positive, 37 gram-negative, 6 anaerobic, and 2 causative of atypical pneumonia) were isolated from sputum cultures, showing high isolation frequencies of Pseudomonas aeruginosa and Staphylococcus aureus and extremely low isolation frequencies of Streptococcus pneumoniae and Haemophilus influenzae. “History of hospitalization within 90 days before the onset of pneumonia” was the most common risk factor, and most of the patients had two or three risk factors. Initially, monotherapy [mainly tazobactam/piperacillin (TAZ/PIPC), sulbactam/ampicillin (SBT/ABPC), ceftriaxone (CTRX), cefepime (CPFM), carbapenems, or fluoroquinolones] or combination therapy (beta-lactam and fluoroquinolone) were administered and gave clinical effects in 63% (22/35) of cases. Bacteriological effects were seen in most strains (57%; 40/70). Since the causative organisms of HCAP were closely related to those of hospital-acquired pneumonia and not to community-acquired pneumonia, we believe that aggressive chemotherapy using broad-spectrum antimicrobials is needed in the initial treatment.     

Epidemiological features and prognosis of severe community-acquired pneumococcal pneumonia

Objective: To describe risk factors of severe pneumococcal community-acquired pneumonia and to study variables influencing outcome. Design: Retrospective (1987–1992) and prospective (1993–1995) study. Setting: Three participating ICUs from primary care hospitals. Patients: Five hundred and five patients (mean age: 63 ± 17 years) with severe community-acquired pneumonia (CAP). Three groups of patients were defined: pneumococcal CAP (group 1), CAP with microbial diagnosis other than Streptococcus pneumoniae (group 2), CAP from group 2 and CAP without microbial diagnosis (group 3). Measurements and results: Admission data and data on the disease's course were recorded. The mean Simplified Acute Physiologic Score (SAPS) was 12.5 ± 5.4. On admission 288 (57 %) patients were mechanically ventilated (mv) and 82 (16.2 %) required inotropic support. A microbial diagnosis was established for 309 (61.2 %) patients. S. pneumoniae was isolated in 137 (27.1 %) patients. Severe pneumococcal CAP was independently associated with male sex (p = 0.01), lack of antibiotics use before admission (p = 0.0001), non-aspiration pneumonia (p = 0.01) and septic shock (p = 0.0001). The overall mortality rate was 27.5 % (29.2 % in group 1). In patients with severe pneumococcal CAP, multivariate analysis showed that leukopenia less than 3,500/mm³ (p = 0.0004), age over 65 years (p = 0.01), septic shock (p = 0.01), sepsis related complications (p = 0.0001), ICU complications (p = 0.001) and inadequacy of antimicrobial therapy (p = 0.002) worsened the prognosis. Conclusions: Few features facilitate the identification of pneumococcal CAP on ICU admission. The prognosis is mostly related to severity of illness (leukopenia, septic shock) while comorbidities do not seem to influence outcome. Sepsis-related disorders, ICU complications and adequate antimicrobial chemotherapy are the major variables affecting the outcome during an ICU stay. Received: 11 May 1998 Final revision received: 11 December 1998 Accepted: 18 December 1998     

Procalcitonin and severity of community-acquired pneumonia

The purpose of this study was to clarify the relationship between procalcitonin and the severity and prognosis of community-acquired pneumonia. The subjects were 162 patients with community-acquired pneumonia (disease severity, mild, 39 patients; moderate, 81 patients; severe, 37 patients; and super severe, 5 patients) in whom we examined the serum procalcitonin concentration at the start of treatment; we determined the relationship of procalcitonin status with disease severity and prognosis. The results showed that procalcitonin was positive in 12.8% of the patients with mild disease, 27.1% of the patients with moderate disease, 59.5% of the patients with severe disease, and 80.0% of the patients with super severe disease. The mortality of procalcitonin-positive patients was 37.7%, whereas that of the procalcitonin-negative patients was 12.8%. Based on the above findings, it is concluded that the more severe the community-acquired pneumonia, the higher is the positivity rate for procalcitonin, and the prognosis in procalcitonin-positive patients is worse than that in procalcitonin-negative patients.