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Abstract

Case Reports: This is a 36 year old man with no significant past medical history who presented to a local hospital with several days of prodromal viral symptoms: fevers, chills, cough. During early hospitalization, he quickly decompensated for unknown reasons, developing acute respiratory distress syndrome (ARDS), requiring mechanical ventilation, and transfer to higher level of care for the initiation of extracorporeal membrane oxygenation (ECMO). The patient received veno-venous ECMO for approximately 7 days. During that time, procalcitonin levels were measured daily and trended while the patient required antibiotic therapy, along with temperature and white blood cell (WBC) count. As the patient clinically improved as evident by temperature, WBC count, and hemodynamics, there was a down-trend in his procalcitonin levels. Antibiotics were discontinued after 7 days. During his hospital course, the patient had several episodes of fever associated with increased expectoration. Interestingly, with each subsequent episode of hospital-acquired pneumonia, procalcitonin levels had risen prior to antimicrobial resumption, decreased with antibiotic therapy, and were consistent with fever trends. Discussion: Antibiotic resistance has become an important factor affecting patient outcome in the intensive care unit. With the overuse of broad spectrum antibiotics, we are heading towards extreme drug resistance especially with gram-negative bacilli. Stewardship programs are looking at biomarkers to help guide duration of antibiotics. Procalcitonin is a fairly specific biomarker for severe bacterial infection in patients with suspected sepsis. A strong correlation exists between concentration of procalcitonin and the extent and severity of bacterial infection. By following the levels of procalcitonin, a few studies have already suggested protocols to shorten antibiotic duration. Even in the setting of ECMO-induced cytokine storm, procalcitonin levels seem to remain unaffected by ongoing systemic inflammation. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010; 375: 463-74.