Effect of Introducing Procalcitonin on Antimicrobial Therapy Duration in Patients With Sepsis and/or Pneumonia in the Intensive Care Unit

Abstract

Background: Utilizing procalcitonin (PCT) levels to limit antimicrobial overuse would be beneficial from a humanistic and economic perspective. Objective: To assess whether introducing PCT at a teaching hospital reduced antimicrobial exposure in critically ill patients. Methods: Patients wereadmitted to the intensive care unit (ICU) for >72 hours with sepsis and/or pneumonia. PCT levels were drawn on admission to the ICU or with new suspected infection, with at least 1 PCT level being drawn at least 48 hours later. Patients were matched in a 1:1 fashion to historical patients on age, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, gender, and primary diagnosis. The primary outcome was duration of initial antimicrobial exposure defined as days from initiation of antimicrobial therapy to the intentional discontinuation of therapy by the physician. Secondary end points included length of stay, readmission to the hospital, and relapse of infection. Results: There were 50 patients in the PCT group and 50 patients in the historical group. The initial duration of antimicrobials was 10 (±4.9) days compared with 13.3 (±7.2), which was statistically significant ( P = .0238). The duration of stay in the hospital (13.5 compared with 17.8 days; P = .0299), readmission to the hospital (9 compared with 17; P = .055), and relapse of infection (3 compared with 11; P = .02) were seen less in the PCT group compared with controls. Conclusion: Introducing PCT levels resulted in a shorter duration of initial antimicrobial therapy and was not associated with adverse treatment outcomes.

Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature

“…The authors cited modest adherence and lack of serial PCT measurements as potential factors contributing to the lack of observed benefits. In other studies, adherence to PCT algorithms varies greatly, ranging from 47–97% …”

“…Among critically ill patients, PCT monitoring also demonstrated a reduction in antibiotic therapy duration when compared with standard care, ranging from 1.7-3.8 days (Table 4). 37,[50][51][52][53][54][55] A multicenter randomized trial conducted in 1546 ICU patients with assumed or probable infection noted a 5.4% absolute difference in 28day mortality between PCT and standard-of-care groups (95% CI 1.2-9.5, p=0.0122) and a 7.4% absolute difference in 1-year mortality (95% CI 1.3-13.8, p=0.0188). 51 Most studies conducted in critically ill or septic patients showed no difference in overall hospital or ICU length of stay with PCT monitoring.…”

Compliance with Procalcitonin Algorithm Antibiotic Recommendations for Patients in Medical Intensive Care Unit

“…Indeed, when a PCT algorithm was combined with twice/week infectious disease stewardship rounds in a randomized trial in the antibiotic continuation setting, compliance with PCT algorithm recommendations was above 97% . In an ICU patient population with low mortality risk, implementation of PCT assays partnered with an active antimicrobial stewardship program in clinical practice was shown to decrease antimicrobial use and hospital length of stay . Previous investigators have, at least partially, attributed PCT algorithm overruling to the reluctance of clinicians to comply with algorithm recommendations in patients who have not clinically improved (and instead relying predominantly on their clinical judgment) .…”

“…10 In an ICU patient population with low mortality risk, implementation of PCT assays partnered with an active antimicrobial stewardship program in clinical practice was shown to decrease antimicrobial use and hospital length of stay. 27 Previous investigators have, at least partially, attributed PCT algorithm overruling to the reluctance of clinicians to comply with algorithm recommendations in patients who have not clinically improved (and instead relying predominantly on their clinical judgment). 5 In fact, the expert authors of a systematic review recommended empirical overruling of a PCT algorithm in a critically ill patient in the initiation setting when a clinical suspicion for infection exists and continuation of antibiotics in the follow-up setting when patients are clinically unstable.…”

Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective

“…It is important to emphasize that the savings associated with PCT-guided care is not associated with any meaningful differences in quality, which has been a consistent finding of clinical effectiveness studies of PCT to date [5,30,34,38,52,78,79]. Moreover, our calculations take into account the costs of the tests and the administration of the tests.…”