The role of lung ultrasound in procalcitonin-guided antibiotic discontinuation in ventilator-associated pneumonia

Abstract

Background and Aims: Starting antibiotic therapy at the proper time is the cornerstone of the management of ventilator-associated pneumonia (VAP). However, using antibiotics for a long duration of therapy in intensive care leads to increased bacterial resistance, financial burden and adverse drug reactions. We hypothesised that lung ultrasound may have a role in guiding antibiotic discontinuation in patients with VAP that will help to reduce the antibiotic duration and decrease the resistance. Methods: This was a prospective blinded cohort study from October 2020 to September 2021 in which 62 VAP patients were recruited. Antibiotics were started, procalcitonin (PCT) level and clinical pulmonary infection score were estimated and lung ultrasound (US) was performed on day 1 and repeated on day 7. On day 7, discontinuation of antibiotics was recommended if the PCT level was <0.25 μg/L. A lung reaeration score was recorded. Results: Based on the PCT levels, antibiotics were discontinued in 40 patients. The computed tomography findings of VAP had improved in all. The ultrasound reaeration score showed a highly significant negative correlation with the PCT on day 7 (-0.718, P < 0.001). A cut-off of 5 for the US score showed a sensitivity of 92.5%, specificity of 95.5%, positive predictive value of 97.4% and negative predictive value of 87.5% in detecting a low PCT score on day 7. Conclusion: Lung US is a non-invasive and safe method that can be used to guide antibiotic therapy in VAP.

Recent advancements in critical care: Part I

“…Furthermore, a study evaluating lung ultrasound and scoring for reaeration has shown a good correlation with procalcitonin level and antibiotic discontinuation. [ 11 ] Therefore, lung ultrasound use in patients with VAP for diagnosis and resolution appears justifiable.…”

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“…Biomarkers such as cardiac biomarkers, autoantibodies, procalcitonin, serum cystatin C and others help in multiple ways including judging the progress of disease, response to therapy and giving warning regarding the development of organ dysfunction. [ 6 7 ]…”

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“…This trend was evident in IJA, which published 12 original articles exploring the use of USG for haemodynamic assessment, fascial plane nerve blocks, and assessment of the adequacy of ventilation and weaning. [ 3 17 22 26 27 28 29 30 31 32 33 34 ] Some innovative applications of USG include the estimation of the gastric residual volume in pre-operative patients, measurement of the cross-sectional area of the dural sac to determine the dose of local anaesthetic, and assessment of lung parenchyma and diaphragm to help weaning from mechanical ventilation. [ 27 31 33 ]…”