Procalcitonin to Guide Antibacterial Prescribing in Patients Hospitalised with COVID-19

Abstract

Antibacterial prescribing in patients presenting with COVID-19 remains discordant to rates of bacterial co-infection. Implementing diagnostic tests to exclude bacterial infection may aid reduction in antibacterial prescribing. (1) Method: A retrospective observational analysis was undertaken of all hospitalised patients with COVID-19 across a single-site NHS acute Trust (London, UK) from 1 December 2020 to 28 February 2021. Electronic patient records were used to identify patients, clinical data, and outcomes. Procalcitonin (PCT) serum assays, where available on admission, were analysed against electronic prescribing records for antibacterial prescribing to determine relationships with a negative PCT result (<25 mg/L) and antibacterial course length. (2) Results: Antibacterial agents were initiated on admission in 310/624 (49.7%) of patients presenting with COVID-19. A total of 33/74 (44.5%) patients with a negative PCT on admission had their treatment stopped within 24 h. A total of 6/49 (12.2%) patients were started on antibacterials, but a positive PCT saw their treatment stopped. Microbiologically confirmed bacterial infection was low (19/594; 3.2%) and no correlation was seen between PCT and culture positivity (p = 1). Lower mortality (15.6% vs. 31.4%; p = 0.049), length of hospital stay (7.9 days vs. 10.1 days; p = 0.044), and intensive care unit (ICU) admission (13.9% vs. 40.8%; p = 0.001) was noted among patients with low PCT. (3) Conclusions: This retrospective analysis of community acquired COVID-19 patients demonstrates the potential role of PCT in excluding bacterial co-infection. A negative PCT on admission correlates with shorter antimicrobial courses, early cessation of therapy, and predicts lower frequency of ICU admission. Low PCT may support decision making in cessation of antibacterials at the 48–72 h review.

Bacterial and Fungal Co-Infections and Superinfections in a Cohort of COVID-19 Patients: Real-Life Data from an Italian Third Level Hospital

“…Hughes et al [ 26 ] highlighted a high prescription rate of antibiotics in patients with COVID-19 pneumonia, with special reference to antibiotics against Gram-negative microorganisms. Our antibiotic use data confirm their observation.…”

“…In fact, in our COVID-19 wards, the most used antibiotic was piperacillin/tazobactam, a beta-lactam/beta-lactamase inhibitor combination which use is highly recommended in community bacterial pneumonitis needing admission in hospital, but also in UTI, abdominal infections, and infections caused by sensitive Gram-negative bacteria. Hughes also studied an approach based on the use of procalcitonin (PCT) to stratify people at risk of having a bacterial co-infection or superinfection within the first 72 h from admission in order to reduce the improper use of empiric antibiotics [ 26 ].…”

“…To fight the inflammatory syndrome, many immunomodulant agents are used, such as corticosteroids, anti-interleukin-1 (IL-1), anti-interleukin-6 (IL-6), and inhibitors of the JAK-STAT pathway [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. The use of immune suppressive drugs, combined with the natural immune suppression caused by the virus, can lead to a surge of secondary bacterial and fungal infections [ 8 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].…”

Procalcitonin Testing With Secondary Coinfection in Patients With COVID-19

“…Studies of COVID-19 patients have documented stopping antibiotics in patients with normal PCT without an increase in mortality [ 17 ]. Another study showed that normal PCT on admission correlates with shorter antimicrobial courses and early stopping of therapy as well as predicts a lower frequency of ICU admission [ 18 ]. The difference in our results and others could be for many reasons.…”

Procalcitonin Increase Is Associated with the Development of Critical Care-Acquired Infections in COVID-19 ARDS

“…The microbiologically confirmed diagnosis of infection has been shown to represent 50–75% of infections on the ICU, and it is currently unknown which is the best way to approach the diagnosis of culture-negative suspected bacterial infections in the context of COVID-19 ARDS [ 34 ]. Biomarkers associated with the development of such infections could be useful tools at the bedside [ 35 ].…”