Procalcitonin to guide antibiotic decision making

Abstract

Purpose of review There is convincing evidence linking antibiotic-stewardship efforts which include the infection marker procalcitonin (PCT) to more rational use of antibiotics with improvements in side-effects and clinical outcomes. This is particularly true in the setting of respiratory infection and sepsis. Yet, some recent trials have shown no benefit of PCT-guided care. Our aim was to discuss the benefits and limitations of using PCT for early infection recognition, severity assessment and therapeutic decisions in individual patients based on most the recent study data. Recent findings Current evidence from randomized trials, and meta-analyses of these trials, indicates that PCT-guided antibiotic stewardship results in a reduction in antibiotic use and antibiotic side-effects, which translates into improved survival of patients with respiratory infections and sepsis. Notably, initial PCT levels have been found to be helpful in defining the risk for bacterial infection in the context of a low pretest probability for bacterial infections (i.e., patients with bronchitis or chronic bastructive pulmonary disease exacerbation). Monitoring of repeated PCT measurements over time has also been found helpful for estimating recovery from bacterial infection and prognosis in higher risk situations (i.e., pneumonia or sepsis) and results in early and safe discontinuation of antibiotic therapy. Some trials, however, did not find a strong effect of PCT guidance which may be explained by low protocol adherence, assessment using only a single rather than repeat PCT levels and lower antibiotic exposure in control group patients. Using PCT in the right patient population, with high-sensitivity assays and with adequate training of physicians is important to increase protocol adherence and reduce antibiotic exposure. Summary Inclusion of PCT into antibiotic stewardship algorithms has the potential to improve the diagnostic and therapeutic management of patients presenting with respiratory illnesses and sepsis, and holds great promise to mitigate the global bacterial resistance crisis and move from a default position of standardized care to more personalized treatment decisions.

Best-practice IgM- and IgA-enriched immunoglobulin use in patients with sepsis

“…The biomarker thresholds for starting IgM and IgA enriched immunoglobulin therapy have not been well-defined for most of the listed parameters (PCT, IL-6 and CRP). As an example of biomarker-driven interventions, Branche et al [101] suggest a PCT cut-off of > 0.5 μg/L for antibiotic use. Conversely, rather than threshold values serving as an indicator for starting therapy, observing the kinetics of these biomarkers may better serve to indicate the effectiveness of overall treatment and assist in the determination of the required duration of therapy.…”

Update on diagnosis and management of sepsis in cirrhosis: Current advances

“…The Surviving Sepsis Campaign guidelines advocate that measuring PCT can help reduce the duration and promote early discontinuation, escalation, or de-escalation of antimicrobial therapy in patients with diagnosed sepsis. Even though single PCT measurements do not have strong prognostic value, serial measurements can help identify patients at risk of death due to the progression of sepsis and the emergence of septic shock[ 48 , 49 ].…”

Enhanced Detection of Community-Acquired Pneumonia Pathogens With the BioFire® Pneumonia FilmArray® Panel

“…Elevations of serum PCT indicate activation of innate immunity ( Gilbert, 2020 , Gilbert, 2017 ). PCT gene activation does not occur with pure viral infection but promptly increases in response to invasion by bacteria to include dual infection with a virus ( Branche et al, 2019 , Schuetz et al, 2017 , US Food and Drug Administration 2017 ). The other variables that influence PCT serum levels; e.g., impaired renal function, are known ( Gilbert, 2020 ).…”