Effects of procalcitonin on antimicrobial treatment decisions in patients with coronavirus disease 2019 (COVID-19)

Abstract

Objective: To describe the natural course of procalcitonin (PCT) in patients with coronavirus disease 2019 (COVID-19) and the correlation between PCT and antimicrobial prescribing to provide insight into best practices for PCT data utilization in antimicrobial stewardship in this population. Design: Single-center, retrospective, observational study. Setting: Michigan Medicine. Patients: Inpatients aged ≥18 years hospitalized March 1, 2020, through October 31, 2021, who were positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2), with ≥1 PCT measurement. Exclusion criteria included antibiotics for nonpulmonary bacterial infection on admission, treatment with azithromycin only for chronic obstructive pulmonary disease (COPD) exacerbation, and pre-existing diagnosis of cystic fibrosis with positive respiratory cultures. Methods: A structured query was used to extract data. For patients started on antibiotics, bacterial pneumonia (bPNA) was determined through chart review. Multivariable models were used to assess associations of PCT level and bPNA with antimicrobial use. Results: Of 793 patients, 224 (28.2%) were initiated on antibiotics: 33 (14.7%) had proven or probable bPNA, 125 (55.8%) had possible bPNA, and 66 (29.5%) had no bPNA. Patients had a mean of 4.1 (SD, ±5.2) PCT measurements if receiving antibiotics versus a mean of 2.0 (SD, ±2.6) if not. Initial PCT level was highest for those with proven/probable bPNA and was associated with antibiotic initiation (odds ratio 95% confidence interval [CI], 1.17–1.30). Initial PCT (rate ratio [RR] 95% CI, 1.01–1.08), change in PCT over time (RR 95% CI, 1.01–1.05), and bPNA group (RR 95% CI, 1.23–1.84) were associated with antibiotic duration. Conclusions: PCT trends are associated with the decision to initiate antibiotics and duration of treatment, independent of bPNA status and comorbidities. Prospective studies are needed to determine whether PCT level can be used to safely make decisions regarding antibiotic treatment for COVID-19.

The Evolving Challenge of Appropriate Antibiotics Use in Hospitalized COVID-19 Patients: A Systematic Literature Review

“…Two hundred-three studies were excluded because they did not report data on antibiotic use in COVID-19 patients. Of the remaining 77 studies, 29 studies were included in this systematic review [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] ( Table 1 ).…”

“…Of the 29 studies included in the systematic review, 18 studies were on the prevalence of bacterial infection and antibiotics use in hospitalized COVID-19 patients [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]; of these studies, 5 reported on patients admitted to the intensive care unit [ 20 , 21 , 22 , 23 , 24 ]. Four studies reported on the efficacy of early antibiotic use in hospitalized COVID-19 patients [ 25 , 26 , 27 , 28 ]; four studies were on the use of sepsis biomarkers to improve antibiotic use among COVID-19 patients [ 29 , 30 , 31 , 32 ]; three studies were on the efficacy of antimicrobial stewardship programs and predictive models among COVID-19 hospitalized patients [ 33 , 34 , 35 ].…”

“…Among the 29 included studies, 23 studies were retrospective, observational studies [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 29 , 30 , 35 ]; 4 studies were observational, before–after studies [ 28 , 32 , 33 , 34 ]; and 2 studies were randomized, open-label, controlled trials [ 25 , 31 ].…”

“…Of the 793 patients, 224 (28.2%) were initiated on antibiotics: 33 (14.7%) had proven or probable bacterial pneumonia, 125 (55.8%) had possible bacterial pneumonia, and 66 (29.5%) had no bacterial pneumonia. Among patients receiving antibiotics, the initial median procalcitonin level was 0.20 ng/mL for those with no bacterial pneumonia, 0.65 ng/mL for those with possible bacterial pneumonia, and 0.88 ng/mL for those with probable or proven bacterial pneumonia [ 29 ].…”

Antimicrobial Use during the SARS-CoV-2 Pandemic in a Greek Tertiary University Hospital

“…Our findings indicate an association between higher procalcitonin levels and antimicrobial usage. In an observational study of 793 patients with COVID-19 [ 17 ], 28.2% were started on antibiotics. Among these, 14.7% had confirmed bacterial pneumonia, while 55.8% had suspected bacterial pneumonia.…”