Introduction of Procalcitonin Testing and Antibiotic Utilization for Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Abstract

Background: The majority of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are triggered by nonbacterial causes, yet most patients receive antibiotics. Treatment guided by procalcitonin (PCT), a sensitive biomarker of bacterial infection, safely decreases antibiotic use in many controlled trials. We evaluated PCT implementation for inpatients with AECOPD at a large academic hospital. Methods: All patients admitted for AECOPD during the first 6 months of PCT-guided therapy were eligible for inclusion in this retrospective cohort study. Patients with PCT performed were compared with those without PCT. The primary outcome was antibiotic days of therapy (DOT). Secondary outcomes included 30-day readmission and mortality. Results: Of the 238 AECOPD admissions, 73 (31%) had PCT performed. Procalcitonin-tested patients were more likely to meet systemic inflammatory response syndrome (SIRS) criteria, require intensive care unit (ICU)-level care, and have a longer length of stay (LOS) compared with those without PCT. Even after adjustment for these factors, PCT-tested patients received more inpatient DOT and there was no difference in total DOT. However, a low PCT value (<0.25 ng/mL) was associated with a 25.5% ( P ⩽ .001) decrease in intravenous (IV) antibiotic DOT. Guideline-recommended follow-up testing was rare (12%). Procalcitonin measurement had no effect on 30-day readmission or mortality. Conclusions: In this real-world analysis of inpatients with AECOPD, PCT-guided therapy was poorly adopted by providers and was not associated with a decrease in total antibiotic DOT. However, a low PCT level was associated with a 25.5% decrease in IV antibiotic DOT, suggesting increased comfort stepping down from IV to PO therapy.

Diagnostic and Prognostic Roles of Procalcitonin and Other Markers in Pneumonia: A Literature Update

“…According to the results of a retrospective cohort study conducted by Ulrich et al in 2019, in which records of 238 COPD exacerbation cases were evaluated, the duration of antibiotic administration was not shortened in patients directed by PCT within a 6-month period, and no difference was noted in regard to mortality (71). Meanwhile, it was reported that the rate of 30-day readmissions was reduced in the group, in which PCT was measured compared to the group in which it was not worked up (21% vs. 36%).…”

Diagnostic and Prognostic Roles of Procalcitonin and Other Tools in Community-Acquired Pneumonia: A Narrative Review

“…Levels of CRP in combination with PCT is a reliable index for the detection of bacterial infection in these patients. According to the results of a retrospective cohort study conducted by Ulrich et al in 2019, in which records of 238 COPD exacerbation cases were evaluated, the duration of antibiotic administration was not shortened in patients directed by PCT within a 6-month period, and no difference was noted in regard to mortality [72]. Meanwhile, it was reported that the rate of 30-day readmissions was reduced in the group in which PCT was measured compared to the group in which it was not worked up (21 versus 36%).…”

Quality and safety in the literature: January 2020

“…For lower respiratory illnesses, these newer tests include rapid viral panels using PCR and the biomarker procalcitonin, the latter of which may be elevated in bacterial infections. The evidence is mixed for the benefit of procalcitonin to guide antimicrobial prescribing in acute exacerbations of COPD 12–15. C-reactive protein (CRP) is a biomarker that may be elevated in a variety of medical illnesses including infection.…”