2012降钙素原(PCT)急诊临床应用的专家共识

降钙素原在急诊科的临床应用急诊科是一个综合性强的科室，除了危重病人的的抢救外，还承担着基本的分诊工作。

感染是急诊科医生每天都要面临的问题，严重感染又是危重症患者死亡的重要原因之一，所以早期、及时、准确的诊断感染是急诊科医生最关注的问题。

传统的检验指标存在着耗时、敏感性及特异性不高的缺陷。

近年研究发现降钙素原（PCT)可用于感染性疾病的早期诊断、细菌感染与非细菌感染的鉴别诊断、评估感染严重程度及作为调整抗生素的依据。

近年来PCT已应用于急诊临床工作中。

一、概述正常情况下PCT由甲状腺滤泡旁细胞（C细胞）分泌，量极少，且不释放入周围循环血，故血清PCT测定低于0.1ng/mL，甚至检测不到。

自1993年Assicot等证实血清PCT水平升高和感染性疾病相关以来，血清PCT检测已广泛应用于临床鉴别是否存在细菌感染及感染程度的监测。

研究证实PCT本身不能启动炎症，但可放大炎症的级联反应，并可增加嗜中性粒细胞和淋巴细胞表面标志物的表达，抑制多核型白细胞的吞噬和杀菌活性等。

用内毒素诱导后，内毒素或细胞因子抑制PCT分解成降钙素，PCT释放入血，使血中PCT增高。

2-3h后检测血清PCT浓度即升高，6-12h达到峰值，1d内保持较高水平，2d后降到基线水平，半衰期约20-24h。

对于严重肾功能衰竭的病例研究，PCT并不大量升高，也适用于肾衰工人工肾治疗的患者。

由此可见，感染状况下PCT生成快，稳定性好，不受基础疾病的影响，可客观反映感染情况，具有评估病情和观察疗效的价值。

同时PCT浓度的增长反映了从一个健康状态到细菌感染的最严重后果的持续发展过程，与细菌感染严重程度呈正相关。

所以PCT作为一种新的细菌感染诊断与鉴别诊断指标，在国内外已广泛应用临床，并取得了良好效果。

二、降钙素原的实验室检测方法目前降钙素原的实验室检测方法有很多，常用的有以下三种：（1）放射免疫分析法(RIA)：它是利用人工合成的多克隆抗体R2B7特异地识别和连接合成氨基酸降钙素原，因放射性元素的污染致使此法使用受限。

要点总结：《降钙素原指导抗菌药物临床合理应⽤专家共识》降钙素原（PCT）是⽆激素活性的降钙素的前体物质，是由116个氨基酸组成的糖蛋⽩，结构上包括降钙蛋⽩、降钙素和N端残基⽚段。

⽣理情况下，PCT主要由甲状腺C 细胞合成分泌。

PCT消除迅速，半衰期为20~24 h。

健康成⼈⾎清PCT⽔平很低，通常不超过0.05µg/L。

法国学者 Assicot等在1993年⾸先提出，PCT可以作为细菌感染的标志物。

随着时间推移PCT已被⼴泛应⽤于细菌感染性疾病诊断和治疗的重要参考指标，PCT在下呼吸道感染和重症监护病房（ICU）重症感染患者抗菌药物治疗疗程中的指导价值逐渐被认可。

基于此“中国医药教育协会感染疾病专业委员会” 撰写了PCT在怀疑或诊断为成⼈下呼吸道感染和ICU重症感染患者的抗菌药物治疗中的指导作⽤的专家共识。

本⽂将对该专家共识中PCT在诊断中、停药中作⽤以及影响PCT升⾼的⾮感染因素等进⾏解读、归纳和总结。

⼀PCT在辅助细菌感染性疾病诊断中的应⽤▣ 1．临床怀疑不明原因感染及脓毒症时，建议及时⾏PCT检测，以帮助进⼀步明确细菌感染性疾病的诊断。

（⾼证据等级，强推荐）细菌感染时，宿主炎症应答产⽣的促炎因⼦诱导甲状腺以外的组织（如肝脏、肺、肠道等）合成PCT，由于这些组织细胞中缺乏分泌颗粒和转化酶，PCT未经处理即以原形释放⼊⾎，从⽽导致⾎清浓度显著升⾼。

病毒感染时，机体释放的γ⼲扰素可抑制PCT 的产⽣，因此，PCT 是细菌感染较为特异的炎症标志物。

动⼒学数据显⽰，细菌感染可快速诱导PCT产⽣，2~6 h即可升⾼，12 h达峰，临床怀疑是细菌感染性疾病的患者及时检测PCT，有助于细菌感染性疾病的早期诊断。

▣ 2．对于疑似为下呼吸道感染的患者，当 PCT≥0.25µg /L，提⽰细菌感染的可能性⾼，建议启⽤经验性抗菌治疗。

（低证据等级，弱推荐）⼀项荟萃分析显⽰，PCT鉴别细菌（含不典型病原体）和⾮细菌感染的受试者⼯作特征曲线下⾯积（AUC）为 0.72，其中，细菌感染较不典型病原体（军团菌除外）感染升⾼更为显著。

降钙素原（PCT）急诊临床应用的专家共识（下）3 PCT水平监测在脓毒症中的应用3．1 用于脓毒症的诊断和鉴别诊断脓毒症患者的PCT水平明显高于非脓毒症患者，细菌性脓毒症患者的PCT水平显著高于非细菌性脓毒症。

且PCT升高对细菌感染导致的脓毒症特异性很高，因此可作为诊断脓毒症和鉴别严重细菌感染的生物标记物。

如果怀疑脓毒症，建议立刻检查PCT。

目前PCT诊断脓毒症的界值水平为>0．5 rig／ml。

PCT<0．05 ng／ml的患者患高风险细菌性感染的可能性非常小，也几乎不会发生血流感染。

极少数病例因脓毒症起病太快而未达到可检测PCT的时间窗(一般为起病3～6 h)，因此对于有急性症状而PCT水平不高的患者，建议6～12 h后复查PCT。

3．2 PCT与血培养阳性率的关系血培养阳性患者的PCT水平较阴性患者高。

PCT>0．1 nml对于人院第1天血培养阳性的预测敏感度100％，特异性80％。

PCT在0．1～0．5rig／ml时排除血流感染的阴性预测值在87％～99％。

PCT水平高的患者血培养更易获得病原学结果。

有研究证实，社区获得性肺炎的(CAP)患者中，当PCT>0．25 ng／／ml，血培养阳性的可能性更大。

3．3评估脓毒症严重程度和病情进展情况PCT在SIRS、脓毒症、严重脓毒症和脓毒性休克患者的质量浓度依次增高，并且具有统计学差异，与病情的严重程度呈正相关。

PCT 质量浓度从0．5 ng／ml上升超过2 ng／ml时，严重细菌感染或脓毒症的发生率增高。

但是存在严重肝。

肾功能障碍或手术／外伤后的最初几天，PCT在0．5～2 ng／ml可视为正常范围。

PCT水平超过2 rig／ml甚至大于10 rig／ml时，脓毒症、严重脓毒症或脓毒性休克的可能性非常大(超过90％)。

高水平的PCT表明全身炎症反应非常严重，死亡风险很高，应．萨即开始抗生素及其他针对性治疗。

因为PCT与脓毒症的病情严重程度相关，所以动态监测PCT水平的变化趋势可以判断病情进展情况。

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procalcitonin in the prediction of infected necrosis in acnte pancreatitis 2000(Suppl 2)1.洪俊轩.苏锦松术前降钙素原的检测对胆囊炎严重程度的预测价值[期刊论文]-医学信息 2014(27)2.肖小琳降钙素原在细菌感染患儿中的临床价值[期刊论文]-中国当代医药 2013(27)3.李硕.郑亚安慢性阻塞性肺疾病患者急性加重期降钙素原与APACHEⅡ评分的相关性分析[期刊论文]-中华急诊医学杂志2013(3)4.柳建茹.单志刚.李胜朝.王玉朋.孟国良血清降钙素原在早期腹腔感染中的应用价值探讨[期刊论文]-内蒙古中医药 2014(10)5.董素娥在脓毒症患儿早期诊断中检测降钙素原的临床意义[期刊论文]-医学信息 2013(29)6.陆一鸣降钙素原PCT感染诊治新技术[期刊论文]-国际检验医学杂志 2013(20)7.魏捷.孙胜男.吕菁君降钙素原对免疫功能异常的脓毒症患者病情评估和预后判断[期刊论文]-中华急诊医学杂志 2013(8)8.陆一鸣降钙素原PCT感染诊治新技术--早期诊断、快速鉴别、及时评估感染程度、指导抗生素使用[期刊论文]-中华实验和临床感染病杂志（电子版） 2013(3)9.孙胜男.吕菁君.魏捷脓毒症患者降钙素原浓度与病原学感染证据之间的相关性研究[期刊论文]-中华急诊医学杂志 2013(10)10.茹晃耀.劳志刚.戴良成.王素宁.吴昊.宋斐动态监测ICU老年重症肺炎患者血清降钙素原水平的临床意义[期刊论文]-中国当代医药 2013(21)11.贺彬.祝益民.卢秀兰.黄娇甜血清降钙素原对重症儿童病情的预测[期刊论文]-中华急诊医学杂志 2013(7)12.谢江霞.霍开秀.阳书坤.刘雪燕.余坤城早期乳酸清除率和PCT在急诊脓毒性休克患者预后中的评估价值[期刊论文]-热带医学杂志 2013(7)13.陈炜.赵磊.王锁柱.盛博.甄洁.古旭云炎性生物标记物在革兰氏阴性菌血流感染患者早期诊断的价值[期刊论文]-中华急诊医学杂志 2014(3)14.陈昊.乔丽旻.张丽葳.张莉芬.李俊.王毅.奚希相.周超金属基质蛋白酶9与脓毒症性肺损伤关系的研究[期刊论文]-医学研究杂志 2013(10)15.梅春霞.刘娟.徐智.戢福云.吴国明APACHEⅡ评分和降钙素原对肺部感染预后的预测作用[期刊论文]-第三军医大学学报2014(8)引用本文格式：降钙素原急诊临床应用专家共识组降钙素原(PCT)急诊临床应用的专家共识[期刊论文]-中华急诊医学杂志2012(9)。

血清降钙素原检测在儿童感染性疾病中的临床应用专家共识摘要降钙素原（PCT）是早期、严重、侵袭性细菌感染的标志物，血清PCT ＜0.05 μg/L时多不支持细菌感染；血清PCT＞2.00 μg/L需考虑脓毒症并提示病情严重；在进行结果判读时需注意结合临床表现，排除局部感染及非感染因素所致血清PCT升高；动态的血清PCT监测对病情的评估与预后判断非常重要，尤其在重症患儿。

动态血清PCT监测可以指导临床抗菌药物使用，当血清PCT＜0.25 μg/L排除细菌感染时不使用抗菌药物；治疗后当血清PCT＜0.50 μg/L或峰值降低幅度≥80％，结合临床表现，可考虑停用抗菌药物。

对于新生儿期血清PCT的判读需注意排除早期生理性升高及其他因素的影响。

降钙素原（procalcitonin, PCT）是机体在全身炎症反应特别是细菌感染时释放的一种急性可溶性蛋白，是严重细菌感染和脓毒症的早期诊断标志物。

近年来，血清PCT检测和临床应用已获得世界范围认同，广泛应用于感染性疾病的诊断与病情动态监测。

临床实践中，即使是非常有经验的儿科医生，对于区分感染性质及程度仍是一个巨大挑战，尤其在早期诊断和抗菌药物应用上难以选择，甚至导致抗菌药物的滥用。

正确掌握和规范血清PCT检测在儿童感染性疾病中的临床应用具有十分重要的意义，为此，中华医学会儿科学分会医院感染管理与控制专业委员会组织专家在综合大量国内外文献，特别是多中心研究的基础上，通过1年多时间共4轮讨论后制定本共识，目的是使儿科医生科学合理应用血清PCT检测，指导临床诊断和治疗。

一、PCT的生物学特征PCT是降钙素的前体物质，由114~116个氨基酸组成，是一种无激素活性糖蛋白，主要由神经内分泌细胞（包括甲状腺、肺和胰腺组织细胞）表达，经酶切分解为降钙素、羧基端肽和氨基端肽。

PCT是一种免疫活性蛋白，其生物活性包括免疫调节和调节血管收缩等。

PCT在人体内稳定性好，半衰期为20~24 h，血清PCT浓度通常＜0.10 μg/L[1]。

讲义（打印或手写）降钙素原（PCT）就是一种蛋白质，当严重细菌、真菌、寄生虫感染以及脓毒症与多脏器功能衰竭时它在血浆中得水平升高。

自身免疫、过敏与病毒感染时PCT不会升高。

局部有限得细菌感染、轻微得感染与慢性炎症不会导致其升高。

PCT反映了全身炎症反应得活跃程度。

影响PCT水平得因素包括被感染器官得大小与类型、细菌得种类、炎症得程度与免疫反应得状况，就是一种用于细菌感染早期诊断、鉴别诊断、治疗监控及预后判断得具有创新意义得诊断指标。

当发生严重细菌感染与脓毒症时，血浆PCT异常升高，3～6h即可测得，6～12h达高峰，2～3天恢复正常1、降钙素原适应症：①细菌感染与病毒感染得鉴别诊断②帮助SIRS/脓毒症得早期诊断，评估疾病得严重程度及预后③抗生素治疗效果得评估，指导临床抗生素使用④手术与严重创伤患者细菌感染并发症监测⑤胰腺炎鉴别诊断2、降钙素原临床意义（1）细菌感染与病毒感染得鉴别诊断病毒性疾病时PCT不增高或仅轻度增高，一般不会超过1~2 ng,PCT鉴别病毒性疾病得敏感度与特异性均高于传统标记物（如c反应蛋白、白细胞，红细胞沉降率等）。

（2）用于脓毒症得诊断与鉴别诊断2012年9月发表得《降钙素原PCT急诊临床应用得专家共识》（以下简称为“共识”）指出：脓毒症患者得PCT水平明显高于非脓毒症患者。

且PCT升高对细菌感染导致得脓毒症特异性很高，可作为诊断脓毒症与鉴别严重细菌感染得生物标志物。

同时，与单纯得临床检测标准相比，PCT检测可显着提高SIRS/脓毒症诊断得敏感性（97%）与特异性（78%）。

把PCT加入诊断标准后，诊断准确率从0、77提高到0、94。

《共识》指出：PCT在SIRS/脓毒症、严重脓毒症与脓毒症休克患者得质量浓度依次增高，与病情得严重度呈正相关（见上图），目前PCT诊断脓毒症得界值水平为>0、5 ng/ml、PCT<0、05 ng/ml得患者患高风险细菌性感染得可能性非常小，PCT浓度从0、5 ng/ml上升超过2 ng/ml时，严重细菌感染或脓毒症得发生率增高，如果PCT值大于 2 ng/ml甚至大于10 ng/ml时，脓毒症、严重脓毒症或者脓毒症休克得可能性非常大（超过90%），高水平PCT表明全身炎症反应非常严重，死亡风险很高，应立即开始抗生素及针对性治疗。