Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimized clinical use

Abstract

Background: Procalcitonin (PCT)-guided antibiotic stewardship (ABS) has been shown to reduce antibiotics (ABxs), with lower side-effects and an improvement in clinical outcomes. The aim of this experts workshop was to derive a PCT algorithm ABS for easier implementation into clinical routine across different clinical settings. Methods: Clinical evidence and practical experience with PCT-guided ABS was analyzed and discussed, with a focus on optimal PCT use in the clinical context and increased adherence to PCT protocols. Using a Delphi process, the experts group reached consensus on different PCT algorithms based on clinical severity of the patient and probability of bacterial infection. Results: The group agreed that there is strong evidence that PCT-guided ABS supports individual decisions on initiation and duration of ABx treatment in patients with acute respiratory infections and sepsis from any source, thereby reducing overall ABx exposure and associated side effects, and improving clinical outcomes. To simplify practical application, the expert group refined the established PCT algorithms by incorporating severity of illness and probability of bacterial infection and reducing the

Biomarkers of Infection: Are They Useful in the ICU?

“…2). 21 Instead of one cutoff, these guidelines recommended cutoff ranges with higher and lower positive and negative predictive values for sepsis. Fig.…”

“…ICU, intensive care unit; PCT, procalcitonin. (Adapted from Schuetz et al 21 ) In this context it is important to emphasize that any diagnosis should not only be based on a specific biomarker but rather in conjunction with the pretest probability based on the clinical assessment and other laboratory results.…”

“…49,50 In this context, PCT has gained much attention lately. Its advantages as well as its limitations are well known and its use to guide antibiotic treatment recently has been approved by FDA, 21 based on a series of randomized trials showing efficacy and safety.…”

“…39 Despite the current body of evidence for PCT-guided antibiotic discontinuation, a commonly accepted clinical algorithm in critically ill patients was long lacking, which in turn limited a more widespread use of PCT. 21 Still, PCT protocols used in the different trials were all somewhat similar and based on a similar intuitive concept: in patients with suspicion of sepsis, initial antibiotics were recommended based on clinical grounds, and PCT kinetics over time were used for recommendations regarding early discontinuation of antibiotic therapy. 51 Thereby, PCT cutoffs of <0.5 ng/mL or a decrease of 80 to 90% from the peak level were used to indicate resolution of illness and stopping of treatment in case the clinical course was also favorable.…”

“…2). 21 Importantly, this algorithm has been tested in different interventional trials, which all documented significantly reduced antibiotic exposure and no excess mortality or increase in adverse event rates. However, adherence rates to PCT protocols were variable, particularly for ICU trials.…”