Patent Publication Number: US-2018052179-A1

Title: Risk assessment for antibiotics treatment in patients suffering from primary non-infectious disease by determining the level of procalcitonin

Description:
REFERENCE TO SEQUENCE LISTING 
     This application contains a Sequence Listing submitted in electronic and print form. The electronic and print form of the Sequence Listing are identical to each other pursuant to 37 CFR §1.52(e)(4), contains the following file: “BOEHMERP0111.txt”, having a size in bytes of 1.37 KB, recorded on Nov. 28, 2011. The information contained in the sequence listing is hereby incorporated by reference in its entirety pursuant to 37 CFR §1.52(e)(5). 
     Field of the Invention 
     The present invention is in the field of clinical diagnostics. Particularly the present invention relates to the risk assessment in patients suffering from a primary non-infectious disease by determination of the level of Procalcitonin (PCT) in a sample of a patient. 
     Background of the Invention 
     Procalcitonin (PCT) is known to be a marker for bacterial infection and sepsis. High blood or serum levels of this peptide prohormone are indicators for severe infections. 
     In a clinical setting, patients with primary non-infectious diseases often are as a precautionary measure, treated with antibiotics in order to prevent or treat potential infections which may or may not yet be manifested, independently of whether the presence of a bacterial infection has actually been diagnosed. 
     The present invention is based on the surprising finding of the inventors that the treatment of patients suffering from a primary non-infections disease with an antibiotic in order to treat or prevent potential bacterial infections is in a particular group of patients associated with an increased risk of an adverse outcome. Particularly patients having a low blood PCT level are subject to an increased risk when subjected to antibiotics. It is according to the invention advisable to determine the PCT level in a sample of a bodily fluid from a patient suffering from a primary non-infectious disease before starting a potentially harmful antibiotic therapy. High blood or serum PCT levels indicate the presence of a severe bacterial infection or even sepsis and requires the treatment of the respective patient with antibiotics. However, patients suffering from a primary non-infectious disease are up to now not routinely screened for low PCT levels before starting an antibiotics therapy. 
     DESCRIPTION OF THE INVENTION 
     Thus, the present invention relates to a diagnostic method for the identification of a subject suffering from a primary non-infectious disease having an increased risk of an adverse outcome potentially being induced by the administration of an antibiotic to said subject, comprising the steps of:
     (i) providing a sample of a bodily fluid from said subject suffering from a primary non-infectious disease,   (ii) determining in said sample the level of Procalcitonin (PCT) or a fragment thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues,   (iii) correlating the determined level of Procalcitonin (PCT) or a fragment, thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues to a potential risk of having an adverse outcome induced by the administration of an antibiotic.   

     The diagnostic method of the invention is an in vitro method. 
     Said subject suffering from a primary non-infectious disease does not have a bacterial infection, especially does not have a severe bacterial infection, preferably does not exhibit any symptoms of a bacterial infection. The herein described methods according to the invention enable the prediction of an adverse outcome induced by antibiotics for a subject suffering from a primary non-infectious disease. Thus, the herein described methods according to the invention are equally methods of predicting an adverse outcome induced by antibiotics for a subject suffering from a primary non-infectious disease. 
     For the very first time it was found that a very low PCT level indicates an enhanced risk of attracting an adverse outcome for a subject suffering from a primary non-infectious disease when antibiotics are administered to said subject. 
     Thus, in a preferred embodiment if the determined level of Procalcitonin (PCT) or a fragment thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues goes below a certain threshold it is predicted that said subject has an enhanced risk of having an adverse outcome when antibiotics are administered. In contrast thereto, according to the methods of the prior art it was known that below a certain threshold of PCT Procalcitonin (PCT) or a fragment thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues the treatment with antibiotics may not be needed but it was not known that there is a correlation between the determined level of Procalcitonin (PCT) or a fragment thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues and the enhanced risk of an adverse outcome induced by antibiotics treatment for said subjects. 
     According to the prior art suspected bacterial infections were often treated with antibiotics without evidence of clinically relevant bacterial disease. It was recommended to administer antibiotics only in case of having the evidence of a clinically relevant bacterial disease in order to save money, in order to avoid side effects or avoid the spread of antibiotic-resistant bacteria. It is a achievement of the present invention to predict the enhanced risk of having severe side-effects or having an adverse outcome induced by antibiotics by correlating a determined level of Procalcitonin (PCT) or a fragment thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues to said risk. 
     Thus, the determination of the level of Procalcitonin (PCT) or a fragment thereof or a precursor or fragment thereof having a length of at least 12 amino acid residues before treatment of subjects suffering from a primary non-infectious disease with antibiotics is an absolutely unavoidable measure in order to identify those subjects which have an enhanced risk of having an adverse outcome induced by antibiotics. 
     Said outcome is preferably an adverse event. An adverse event is defined as an event compromising the health of an individual. Said adverse event is not restricted to but may be selected from the group comprising a coronary event, cardiovascular event, death, heart failure, diabetes, hypertension. Coronary events are defined as fatal or non-fatal acute coronary syndromes including myocardial infarction, or death due to ischemic heart disease. Cardiovascular events are defined as fatal or non-fatal acute coronary syndromes including myocardial infarction, fatal or non-fatal stroke, or death due to cardiovascular disease. 
     Said adverse outcome may be side-effects induced by antibiotics treatment, especially severe side effects induced antibiotics treatment. Such side effect may include such as upset stomach, diarrhea, and, in women, vaginal yeast infections. Some subjects may be allergic to antibiotics. 
     Said outcome or said risk may for instance regard the survival and/or a functional outcome. 
     The term “outcome” herein relates for instance to the survival of the patient after a defined time, e.g. after 3 days, 5 days, 10 days, 14 days, 20 days, 3 weeks, 4 weeks, 30 days, 45 days, 60 days, 90 days, 3 months, 6 months, i year, preferably 30 days. 
     The term “functional outcome” in the context of the present invention relates to the degree of severity of disease, i.e. the state of health of the patient after a defined time, e.g. 3 days, 5days, 10 days, 14 days, 20 days, 3 weeks, 4 weeks, 30 days, 45 days, 60 days, 90 days, 3months, 6 months, 1 year, preferably 30 days. 
     The adverse outcome may e.g. be mortality. This means that with the methods of the present invention, subjects can be identified for which the administration of antibiotics would lead to an increased risk of a fatal outcome within a given period, e.g. within 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14, 15, 20, 21, 30, 60, or 90 days after start of the treatment with an antibiotic. 
     The primary non-infectious disease from which the subject suffers may preferably be selected from the group of cardiovascular disease, cardiac disease, cancer, a disease of the CMS, diabetes, autoimmune disorder, and disorder associated with inflammation. 
     Said primary disease may in a particular example be heart failure. The subjects may in a preferred embodiment suffer from heart failure and/or shortness of breath. Heart failure herein preferably relates to congestive heart failure (CHF). The heart failure may preferably be acute heart failure (AHF) or chronic heart failure. 
     Heart failure is a cardiac condition that occurs when a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body&#39;s needs. It can cause a large variety of symptoms, particularly shortness of breath and ankle swelling, but some patients cars be completely symptom free. Heart failure is often undiagnosed due to a lack of a universally agreed definition and challenges in definitive diagnosis, particularly in early stage. With appropriate therapy, heart failure can be managed in the majority of patients, but it is a potentially life threatening condition, and progressive disease is associated with an annual mortality of 10%. It is the leading cause of hospitalization in people older than 65. 
     Shortness of breath (SoB; also known as dyspnea or difficulty breathing) relates to a sensation of difficult or uncomfortable breathing or a feeling of not getting enough air in a subject, SoB may have many different causes, among them heart diseases such as heart attack, congestive heart failure, and pulmonary hypertension. 
     In a particularly preferred embodiment of the present invention, the subject is suffering from shortness of breath and subsequently diagnosed with heart failure. 
     In the context of the present invention a concentration of PCX or a fragment thereof or a precursor or fragment thereof below 200 pg/mL, preferably below 150 pg/mL, more preferably below 100 pg/mL, most preferably below 50 pg/mL, in the sample correlates to an increased risk induced by the potential administration of an antibiotic. 
     These values have been determined with a PCX test format (BRAHMS KRYPTOR PCT sensitive), which has the same calibration in the quantitative measuring range as a more sensitive PCT Assay (BRAHMS PCT LIA sensitive), the latter being able to quantitatively determine PCT levels in the normal population, giving median PCT levels as described in EP 09011073.5 (“Procalcitonin for the prognosis of adverse events in the asymptomatic population”). The above mentioned values might be different in other PCT assays, if these have been calibrated differently from BRAHMS KRYPTOR PCT sensitive. The above mentioned values shall apply for such differently calibrated PCT assays accordingly, taking into account the differences in calibration. One possibility of quantifying the difference in calibration is a method comparison analysis (correlation) of the PCT assay in question with the BRAHMS KRYPTOR PCT sensitive by measuring PCT in samples using both methods. Another possibility is to determine with the PCT assay in question, given this test has sufficient analytical sensitivity, the median PCT level of a representative normal population, compare results with the median PCT levels as described in EP 09011073.5 (“Procalcitonin for the prognosis of adverse events in the asymptomatic population”) and recalculate the calibration based on the difference obtained by this comparison. 
     In a particular embodiment, additionally at least one clinical parameter is determined selected from the group comprising: age, gender, systolic blood pressure, diastolic blood pressure, antihypertensive treatment, history of stroke, wheezing, body mass index, heart rate, temperature, presence of diabetes mellitus and current smoking habits, most preferably selected from the group consisting of heart rate, temperature, body mass index, systolic blood pressure and diastolic blood pressure. 
     In some particular embodiments other laboratory parameters may additionally be determined, e.g. the level of neutrophil granulocyte or the level of further prognostic markers, particularly other peptide hormones and fragments thereof or precursors or fragments thereof. 
     The term “sample” as used herein refers to a sample of bodily fluid obtained for the purpose of diagnosis, prognosis, or evaluation of a subject of interest, such as a patient. Preferred test samples include blood, serum, plasma, cerebrospinal fluid, urine, saliva, sputum, and pleural effusions. In addition, one of skill in the art would realize that some test samples would, be more readily analyzed following a fractionation or purification procedure, for example, separation of whole blood into serum or plasma components. 
     Thus, in a preferred embodiment of the invention the sample is selected from the group consisting of a blood sample, a serum sample, a plasma sample, a cerebrospinal fluid sample, a saliva sample and a urine sample or an extract of any of the aforementioned samples. Preferably, the sample is a blood sample, most preferably a serum sample or a plasma sample. 
     The term “subject” as used herein refers to a living human or non-human organism, preferably a patient that is receiving medical care or that should receive medical care due to a primary non-infectious disease. This includes persons with no defined illness who are being investigated for signs of pathology. Thus, the methods and assays described herein are applicable to both human and veterinary disease. 
     “Fragments” of PCT or precursors thereof relate to fragments of at least twelve amino acid residues in length. 
     PCT in the context of the present invention preferably relates to a peptide spanning the amino acid residues 1-116, 2-116, or 3-116 or fragments thereof Procalcitonin may comprise posttranslational modifications such as glycosylation, liposidation or derivatisation. PCT itself is a precursor of calcitonin and katacalcin. The amino acid sequence of PCT is given in SEQ ID NO: 1 ( FIG. 4 ). 
     The term “level” in the context of the present invention relates to the concentration (preferably expressed as weight/volume; w/v) of PCT (or a fragment-precursor) in the sample taken from the subject. 
     Determining (or measuring or detecting) the level of PCT or a fragment or a precursor or fragment thereof herein is performed using a detection method and/or a diagnostic assay as explained below. 
     As mentioned herein, an “assay” or “diagnostic assay” can be of any type applied in the field of diagnostics. Such an assay may be based on the binding of an analyte to be detected to one or more capture probes (capture molecules) with a certain affinity. Concerning the interaction between capture molecules and target molecules or molecules of interest, the affinity constant is preferably greater than 10 8  M −1 . 
     In the context of the present invention, “capture molecules” are molecules which may be used to bind target molecules or molecules of interest, i.e. analytes (i.e. in the context of the present invention the cardiovascular peptide(s)), from a sample. Capture molecules must thus be shaped adequately, both spatially and in terms of surface features, such as surface charge, hydrophobicity, hydrophilicity, presence or absence of lewis donors and/or acceptors, to specifically bind the target molecules or molecules of interest. Hereby, the binding may for instance be mediated by ionic, van-der-Waals, pi-pi, sigma-pi, hydrophobic or hydrogen bond interactions or a combination of two or more of the aforementioned interactions between the capture molecules and the target molecules or molecules of interest. In the context of the present invention, capture molecules may for instance be selected from the group comprising a nucleic acid molecule, a carbohydrate molecule, a RNA molecule, a protein, an antibody, a peptide or a glycoprotein. Preferably, the capture molecules are antibodies, including fragments thereof with sufficient affinity to a target or molecule of interest, and including recombinant antibodies or recombinant antibody fragments, as well as chemically and/or biochemically modified derivatives of said antibodies or fragments derived from the variant chain with a length of at least 12 amino acids thereof. 
     The preferred detection methods comprise immunoassays in various formats such as for instance radioimmunoassay (RIA), chemiluminescence- and fluorescence- immunoassays, Enzyme-linked immunoassays (ELISA), Luminex-based bead arrays, protein microarray assays, and rapid test formats such as for instance immunochromatographic strip tests. 
     The assays can be homogenous or heterogeneous assays, competitive and non-competitive sandwich assays. In a particularly preferred embodiment, the assay is in the form of a sandwich assay, which is a non-competitive immunoassay, wherein the molecule to he detected and/or quantified is bound to a first antibody and to a second antibody. The first antibody may be bound to a solid phase, e.g. a bead, a surface of a well or other container, a chip or a strip, and the second antibody is an antibody which is labeled, e.g. with a dye, with a radioisotope, or a reactive or catalytically active moiety. The amount of labeled antibody bound to the analyte is then measured by an appropriate method. The general composition and procedures involved with “sandwich assays” are well-established and known to the skilled person. ( The Immunoassay Handbook, Ed.  David Wild. Elsevier LTD, Oxford; 3rd ed. (May 2005), ISBN-!3:978-0080445267; Hultschig C et al.,  Curr Opin Client Biol  2006Feb; 10(1):4-10, PMID: 16376134), incorporated herein by reference). 
     In a particularly preferred embodiment the assay comprises two capture molecules, preferably antibodies which are both present as dispersions in a liquid reaction mixture, wherein a first labeling component is attached to the first capture molecule, wherein said first labeling component is part of a labeling system based on fluorescence- or chemiluminescence-quenching or amplification, and a second labeling component of said marking system is attached to the second capture molecule, so that upon binding of both capture molecules to the analyte a measurable signal is generated that allows for the detection of the formed sandwich complexes in the solution comprising the sample. 
     Even more preferred, said labeling system comprises rare earth cryptates or rare earth chelates in combination with a fluorescence dye or chemiluminescence dye, in particular a dye of the cyanine type. 
     In the context, of the present invention, fluorescence based assays comprise the use of dyes, which may for instance be selected from the group comprising RAM (5-or 6-carboxyfluorescein), VIC, NED, Fluorescein, Fluoresceinisothiocyanate (FITC), IRD-700/800, Cyanine dyes, such as CY3, CY5, CY3.5, CY5.5, Cy7, Xanthen, 6-Carboxy-2′,4′,7′,4,7-hexachlorofluorescein (HEX), TET, 6-Carboxy-4,5′-dichloro-2′,7′-dimethodyfluorescein (JOE), N,N,N′,N′-Tetramethyl-6-carboxyrhodamine (TAMRA), 6-Carboxy-X-rhodamine (ROX), 5-Carboxyrhodamine-6G (R6G5), 6-carboxyrhodamine-6G (RG6), Rhodamine, Rhodamine Green, Rhodamine Red, Rhodamine 110, BODIPY dyes, such as BODIPY TMR, Oregon Green, Coumarines such as Umbelliferone, Benzimides, such as Hoechst 33258; Phenanthridines, such as Texas Red, Yakima Yellow, Alexa Fluor, PET, Ethidiumbromide, Acridinium dyes, Carbazol dyes, Phenoxazine dyes, Porphyrine dyes, Polymethin dyes, and the like. 
     In the context of the present invention, chemiluminescence based assays comprise the use of dyes, based on the physical principles described for chemiluminescent materials in Kirk-Othmer, Encyclopedia of chemical technology, 4 th  ed., executive editor, J. I. Krosehwitz; editor, M. Howe-Grant, John Wiley &amp; Sons, 1993, vol. 15, p. 518-562, incorporated herein by reference, including citations on pages 551-562, Preferred chemiluminescent dyes are acridiniumesters. 
     The present invention also relates to the use of a method according to the invention for the stratification of subjects suffering from a primary non-infectious disease into a group of subjects having an increased risk of an adverse outcome induced by the administration of an antibiotic and a group of subjects having no risk induced by the administration of an antibiotic. 
     Furthermore, the invention pertains to the use of a kit comprising one or more antibodies directed against PCT or a fragment thereof or a precursor or fragment thereof for the stratification of subjects suffering from a primary non-infectious disease into a group of subjects having an increased risk of an adverse outcome induced by the administration of an antibiotic and a group of subjects having no risk induced by the administration of an antibiotic. 
     Sequences 
       
     
       
         
           
               
               
            
               
                 SEQ ID NO: 1 (amino acid sequence of PCT) 
                   
               
            
           
           
               
               
               
            
               
                   1 
                 APFRSALESS PADPATLSED EARLLLRALV QDYVQMKASE LEQEQEREGS 
                   
               
               
                   
               
               
                  51 
                 SLDSPRSKRC GNLSTCMLGT YTQDFNKFHT FPQTAIGVGA PGKKRDMSSD 
               
               
                   
               
               
                 101 
                 LERDHRPHVS MPQNAN 
               
            
           
         
       
     
    
    
     
       DESCRIPTION OF DRAWINGS 
         FIG. 1 : Summary of patients in the clinical study of example 1. 
         FIGS. 2A-D :  FIGS. 2A-D  illustrates the survival (in %) of the patients diagnosed with AHF in the study of example 1 over time (in weeks) up to 90 days from admission. Solid lines regard die group of patients that have not received antibiotics treatment, while the dashed lines concern patients treated with antibiotics.  FIG. 2A : all patients diagnosed with AHF (n=561), antibiotics treated: n=104 (18 dead after 90 days), non-antibiotics-treated: n=457 (46 dead after 90 days), p=0.03011;  FIG. 2B : patients diagnosed with AHF and having plasma PCT levels of from 20.7 to 51.1 pg/mL (n−112), antibiotics treated: n=17 (4 dead alter 90 days), non-antibiotics-treated: n=95 (5 dead after 90 days), p=0.00632;  FIG. 2C : patients diagnosed with AHF and having plasma PCT levels of from 51.1 to 205 pg/mL (n=336), antibiotics treated: n=55 (9 dead after 90 days), non-antibiotics-treated: n=281 (24 dead after 90 days), p=0.06328;  FIG. 2D : patients diagnosed with AHF and having plasma PCT levels of from 205 to 230 pg/mL (n=113), antibiotics treated: n=32 (5 dead after 90 days), non-antibiotics-treated: n=81 (17 dead after 90 days), p=0.06328. 
         FIGS. 3A-D :  FIGS. 3A-D  illustrates the survival (in %) of the patients diagnosed with AHF in the study of example 1 over time (in days) up to 90 days from admission. Solid lines regard the group of patients that have not received antibiotics treatment, while the dotted lines concern patients treated with antibiotics.  FIGS. 3A-D  correspond to the same patient groups as in  FIGS. 2A-D , respectively. The data of  FIG. 3  has been adjusted for the occurrence of wheezing, history of stroke and blood level of neutrophil granulocytes in the patients to account for possible differences between the antibiotic treated group and the non-treated group. 
         FIG. 4 : Amino acid sequence of Procalcitonin (PCT), SEQ ID NO:1 
     
    
    
     EXAMPLES 
     Example 1 
     Clinical study: 15 Enrolling Centers—recruiting 1641 patients with shortness of breath (SoB) and acute heart failure (AHF) 
     This study was approved by the institutional review boards of 8 institutions. 1,641 patients from fifteen centers were enrolled from March 2007 to February 2008 that included 8 United States, 6 European and 1 New Zealand center. To be eligible patients had to report shortness of breath as their primary complaint upon presentation to the emergency department. Patients under 18 years of age or unable to provide consent were excluded. Patients with an acute ST-elevation myocardial infarction or on hemodialysis were also excluded. Antibiotics were given to some of the patients at the assessment of the treating physician. 
     For each patient enrolled in the study, the emergency physician, blinded to investigational marker results, assessed the probability that the patient had acute HF or pneumonia via two separate Likert scale questionnaires, assigning a value of 0 to 100 percent clinical certainty. 
     Summary of Study Particulars: 
     
         
         
           
             Patients included who presented to emergency department (ED) with SoB not from trauma, or obvious myocardial infarction (MI), and not on dialysis. 
             After consenting, MD assessment of probability of heart failure and/or pneumonia. 
             Two independent cardiologists agreed on final diagnosis following discharge. 
             Follow-up for 90 days for survival; Outcome “All cause mortality within 90 days”. 
           
         
       
    
     Table 1 and  FIG. 1  further summarize details on the patients in the study. 
     Confirmation of Diagnosis 
     To determine the gold standard diagnosis, two cardiologists independently reviewed all medical records pertaining to the patient and independently classified the diagnosis as dyspnea due to heart failure, pneumonia or due to other underlying cause. Both cardiologists were blinded to each others assessments, the investigational markers, and the emergency physician&#39;s preliminary diagnosis. They had access to the ED case report forms that included medical history plus data on chest radiography, radionuclide angiography, echocardiography, and cardiac catheterization as available, as well as the hospital course for those who were admitted. In the event of diagnostic disagreement between the cardiology reviewers they were asked to meet to come to a common conclusion. In the event they were unable to come to a common conclusion, a third cardiology adjudicator was assigned by the endpoints committee to determine a final diagnosis. In order to come to a diagnosis of pneumonia, criteria modified from Fine et al 1990 and Leroy et al 1995 had to be fulfilled (Leroy et at. Intensive Care Med (1995)21:24-31: Fine et al Am J Med 1990:89:713-721). 
     Measurement of Biomarkers 
     All blood samples were collected in EDTA-containing plastic tubes and plasma was stored at −70° C. in plastic freezer vials, PCT was measured with an automated sandwich chemiluminescence immunoassay on the KRYPTOR System (B.R.A.H.M.S AG, Hennigsdorf, Germany). The assay is based on the sandwich chemiluminescence assay which is described in detail elsewhere (Morgenthaier et al, Clin Chem 2002; 48:788-790). 
     Statistical Analysis 
     Values are expressed as means and standard deviations or counts and percentages as appropriate. Diagnostic groups were compared with independent-samples t-tests and chi-square tests as appropriate. Two primary objectives were evaluated using a p-value of 0.0125 as the significance criterion for each. All other analyses are exploratory and utilized a p-value of 0.05 for significance. The secondary analyses utilized logistic regression, Spearman&#39;s correlation, and ROC curve analysis. Outcome prediction was evaluated using Cox proportional hazard regression models. The predictive value of each model was assessed by the model likelihood ratio chi-square statistic. Survival curves plotted by the Kaplan-Meier method were used for illustrative purposes, and log-rank tests applied to test for survival differences. 
     Results 
     The 90-day-outcome in terms of survival was assessed for patients with shortness of breath that have been diagnosed with acute heart failure (AHF). 
     457 patients diagnosed with AHF had no treatment with antibiotics after entering the study, 104 were given antibiotics. 90 days after admission into the study, 46 of the patients not treated with antibiotics had died (10.1%). Of the patients treated with antibiotics, 18 patients had died until the 90th day (17.3%). 
     The outcome (survival rate) for patients diagnosed with AHF is illustrated in  FIGS. 2A-D . The group of patients without antibiotics treatment are indicated by solid lines, the group of patients with antibiotics treatment is indicated by dashed lines.  FIG. 2A  shows the outcome for patients independent of their plasma PCT level.  FIG. 2B  summarizes patients with plasma PCT levels of from 20.7 to 51.1 pg/mL (n=112),  FIG. 2C  summarizes patients with plasma PCT levels of from 51.1 to 205 pg/mL (n=336),  FIG. 2D  summarizes patients with plasma PCT levels of above 205 pg/mL (n=113). The results demonstrate that for patients with low PCT levels, i.e. below about 205 pg/mL and particularly below about 51.1 pg/mL the survival rate is lower in the group treated with antibiotics than in the non-treated group. 
       FIGS. 3A-D  correspond to the respective  FIGS. 2A-D  except that the results have been adjusted for the covariants “occurrence of wheezing”, “history of stroke” and “blood level of neutrophil granulozytes” in the patients to account for differences between the groups of antibiotics treated and non-treated patients. The results of  FIG. 3  show that in patients with plasma PCT levels below about 51.1 pg/mL the mortality is higher in the antibiotics treated group of patients than in patients that have not been treated with antibiotics. 
     
       
         
           
               
             
               
                 TABLE 1 
               
             
            
               
                   
               
               
                 Patient characteristics by diagnosis 
               
            
           
           
               
               
               
               
               
            
               
                   
                   
                 Non-AHF 
                 AHF 
                   
               
               
                 Variables 
                 N 
                 (N = 1073) 
                 (N = 568) 
                 P 
               
               
                   
               
            
           
           
               
            
               
                 Demographics 
               
            
           
           
               
               
               
               
               
            
               
                 Age 
                 1641 
                 59.8 ± 17.0 
                 71.2 ± 13.8 
                 &lt;0.001 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Male Gender 
                 1641 
                 504 
                 (47.0) 
                 355 
                 (62.5) 
                 &lt;0.001 
               
               
                 Race 
                 1626 
                   
                   
                   
                   
                 &lt;0.001 
               
               
                 White 
                   
                 659 
                 (62.1) 
                 431 
                 (76.3) 
               
               
                 Black 
                   
                 356 
                 (33.6) 
                 120 
                 (21.2) 
               
               
                 Other 
                   
                 46 
                 (4.3) 
                 14 
                 (2.5) 
               
            
           
           
               
            
               
                 Recent History 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Smoking 
                 1593 
                 344 
                 (33.0) 
                 125 
                 (22.7) 
                 &lt;0.001 
               
               
                 Wheezing 
                 1543 
                 359 
                 (35.4) 
                 109 
                 (20.6) 
                 &lt;0.001 
               
               
                 Weight Gain 
                 1438 
                 112 
                 (11.8) 
                 137 
                 (28.0) 
                 &lt;0.001 
               
               
                 Night Sweats 
                 1495 
                 230 
                 (23.4) 
                 94 
                 (18.3) 
                 0.025 
               
               
                 Orthopnea 
                 1536 
                 349 
                 (35.0) 
                 340 
                 (63.0) 
                 &lt;0.001 
               
               
                 Dyspnea at Rest 
                 1605 
                 518 
                 (49.3) 
                 277 
                 (49.9) 
                 0.834 
               
            
           
           
               
            
               
                 Exam Variables 
               
            
           
           
               
               
               
               
               
            
               
                 Heart Rate 
                 1632 
                 92.6 ± 21.6 
                 89.2 ± 24.8 
                 0.005 
               
               
                 Systolic BP 
                 1631 
                 139.7 ± 26.8  
                 143.0 ± 31.8  
                 0.027 
               
               
                 Diastolic BP 
                 1630 
                 79.6 ± 16.4 
                 83.0 ± 18.7 
                 &lt;0.001 
               
               
                 BMI 
                 1399 
                 29.6 ± 9.1  
                 28.5 ± 8.1  
                 0.035 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Rales 
                 1624 
                 216 
                 (20.3) 
                 308 
                 (54.8) 
                 &lt;0.001 
               
               
                 S3 
                 1580 
                 6 
                 (0.6) 
                 38 
                 (7.0) 
                 &lt;0.001 
               
               
                 Murmur 
                 1604 
                 98 
                 (9.3) 
                 156 
                 (28.3) 
                 &lt;0.001 
               
               
                 JVP 
                 1539 
                 71 
                 (7.0) 
                 200 
                 (28.3) 
                 &lt;0.001 
               
               
                 Edema 
                 1615 
                 244 
                 (23.1) 
                 344 
                 (61.5) 
                 &lt;0.001 
               
               
                 Ascites 
                 1579 
                 15 
                 (1.5) 
                 26 
                 (4.8) 
                 &lt;0.001 
               
               
                 Wheezing 
                 1619 
                 350 
                 (33.0) 
                 102 
                 (18.2) 
                 &lt;0.001 
               
            
           
           
               
            
               
                 History Variables 
               
            
           
           
               
               
               
               
               
               
               
            
               
                 Arrhythmia 
                 1555 
                 168 
                 (16.6) 
                 237 
                 (43.6) 
                 &lt;0.001 
               
               
                 Asthma 
                 1594 
                 288 
                 (27.7) 
                 30 
                 (5.4) 
                 &lt;0.001 
               
               
                 CRI 
                 1584 
                 75 
                 (7.2) 
                 171 
                 (31.3) 
                 &lt;0.001 
               
               
                 HF 
                 1597 
                 203 
                 (19.6) 
                 366 
                 (65.2) 
                 &lt;0.001 
               
               
                 CAD 
                 1587 
                 232 
                 (22.3) 
                 271 
                 (49.5) 
                 &lt;0.001 
               
               
                 COPD 
                 1594 
                 341 
                 (32.7) 
                 130 
                 (23.6) 
                 &lt;0.001 
               
               
                 DM 
                 1621 
                 244 
                 (23.1) 
                 218 
                 (38.6) 
                 &lt;0.001 
               
               
                 Hyperlipidemia 
                 1549 
                 330 
                 (32.4) 
                 240 
                 (45.3) 
                 &lt;0.001 
               
               
                 Hypertension 
                 1614 
                 642 
                 (60.9) 
                 438 
                 (78.2) 
                 &lt;0.001 
               
               
                 MI 
                 1584 
                 128 
                 (12.3) 
                 172 
                 (31.5) 
                 &lt;0.001 
               
               
                 Pulmonary Embolism 
                 1604 
                 49 
                 (4.7) 
                 36 
                 (6.5) 
                 0.127 
               
               
                 CABG 
                 1615 
                 66 
                 (6.2) 
                 92 
                 (16.5) 
                 &lt;0.001 
               
               
                 Angioplasty/Stent 
                 1602 
                 96 
                 (9.1) 
                 108 
                 (19.6) 
                 &lt;0.001 
               
               
                 Stroke/CVA 
                 1608 
                 89 
                 (8.5) 
                 76 
                 (13.7) 
                 0.001 
               
               
                 Pacemaker/ICD 
                 1616 
                 55 
                 (5.2) 
                 107 
                 (19.1) 
                 &lt;0.001 
               
               
                 Prosthetic Valve 
                 1612 
                 13 
                 (1.2) 
                 30 
                 (5.4) 
                 &lt;0.001 
               
               
                   
               
               
                 Notes: 
               
               
                 Values are mean ± SD or N(%) and compared with independent samples t-test or Fisher exact tests, respectively.