Clinical Progress Note: Procalcitonin in the Diagnosis and Management of Community‐Acquired Pneumonia in Hospitalized Adults

Abstract

Community-acquired pneumonia (CAP) accounts for more than 1.5 million adult hospitalizations and 100,000 deaths each year in the United States.1 Antibiotic overuse in the hospital setting is an important contributor to the rise of antibiotic resistance, prompting increased efforts to limit inappropriate antibiotic use in hospitals.2 Procalcitonin, a precursor of the hormone calcitonin, is upregulated in bacterial infections and downregulated in viral infections. The US Food and Drug Administration has approved it as a serum biomarker to assist clinicians with decisions about using antibiotics.3 There is no consensus on how to best use procalcitonin in the management of CAP. We provide a practical update that includes a review of recent literature, added secondary analysis, and expert opinion surrounding the use of procalcitonin in the diagnosis and management of CAP in hospitalized adults.

Clinical Progress Note: Procalcitonin in the Management of Pediatric Lower Respiratory Tract Infection

“…Multiple studies have evaluated the potential utility of PCT in guiding antibiotic initiation in adults with LRTI, but data on pediatric patients are sparse. 4 In a randomized, single-center Italian study comparing a PCT-guided algorithm (withholding antibiotics when PCT < 0.25 µg/L) versus usual care among 319 hospitalized children with pneumonia, the PCT group experienced fewer antibiotic initiations (15.5% vs 100%, P < .05) without significant differences in recurrence of respiratory symptoms or new antibiotic prescriptions in the month following enrollment. 2 A similar randomized trial using a PCT-guided algorithm for the initiation of antibiotics conducted among 337 Swiss children presented to the emergency department (ED) with pneumonia and other LRTIs failed to demonstrate decreases in antibiotic initiation.…”

“…Currently available data demonstrate the value of serial PCT measurements in antibiotic de-escalation and promoting antibiotic stewardship for children and adults. [2][3][4] As with all new diagnostic modalities, provider education is paramount to ensure a safe and value-driven implementation.…”

“…Atypical bacterial infections (ie, Mycoplasma pneumoniae) and localized bacterial infection may not induce significant PCT production, as has been shown in adults and children with tonsillitis, localized skin infections, endocarditis, or empyema (Table). 12 The majority of clinical trials in LRTI have been conducted in the adult population, 4 with the number of pediatric trials remaining small 2,3 . Given the predominance of viral LRTI in children compared with adults, the utility of PCT may differ in these populations 13,14 .…”

“…The utility of PCT for antibiotic initiation in the pediatric population is encouraging given the predominance of viral etiologies in pediatric LRTI. Currently available data demonstrate the value of serial PCT measurements in antibiotic de‐escalation and promoting antibiotic stewardship for children and adults 2‐4 . As with all new diagnostic modalities, provider education is paramount to ensure a safe and value‐driven implementation.…”

“…The commonly used PCT cut points for withholding or stopping antibiotics in adults and children are 0.1 µg/L (very low risk of bacterial etiology) or 0.25 µg/L (low risk of bacterial etiology). [2][3][4] Among the 532 children enrolled in the multicenter study of Etiology of Pneumonia in the Community (EPIC), a PCT threshold of 0.25 µg/L demonstrated an approximate sensitivity of 85%, specificity of 45%, positive likelihood ratio of 1.55, and negative likelihood ratio of 0.33 for community acquired pneumonia (CAP) caused by typical bacterial pathogens. 5 Lowering the cutoff to <0.1 µg/L increased PCT sensitivity to 100%, decreased specificity, positive likelihood ratio, and negative likelihood ratio to 20%, 1.26, and 0, respectively.…”