Procalcitonin Group Research Articles

Biomarker guided antibiotic stewardship in community acquired pneumonia: A randomized controlled trial.

In community-acquired pneumonia (CAP), the role of biomarkers to shorten duration of antibiotic treatment has not been firmly established. We assessed the effectiveness of active feedback of treatment algorithms based on procalcitonin (PCT) and C-reactive protein (CRP), compared to standard care, on the duration of antibiotic treatment in patients hospitalized with community-acquired pneumonia (CAP) in non-ICU wards. We performed a randomised, open label, parallel group, multi-centre trial in 3 Dutch teaching hospitals. Treatment was guided by a PCT algorithm, CRP algorithm or standard care. Participants were recruited by a member of the study team and randomised at day 2-3 of admission in a 1:1:1 ratio. Treatment was discontinued upon predefined thresholds of biomarkers that were assessed on admission, day 4 and days 5-7 if indicated. The primary outcome was total days on antibiotic treatment until day 30. In total 468 participants were included in this study. The median days on antibiotics (IQR) was 7 (IQR 7-10) in the control group, 4 (IQR 3-7) in the CRP group (rate ratio (RR) of 0.70, 95% CI 0.61-0.82 compared to standard care; p <0.001), and 5.5 (IQR 3-9) in the PCT group (RR of 0.78, 95% CI 0.68-0.89 compared to standard care; p <0.001). New antibiotics within the first 30 days were prescribed to 24, 23 and 35 patients in standard care, CRP and PCT groups, respectively. The hazard ratio for a new prescription in patients in the PCT group compared to standard care 1.63 (CI 0.97-2.75; p = 0.06). No difference in time to clinical stability or length of stay was found. A strategy of feedback of CRP-guided and PCT-guided treatment algorithms reduced the number of days on antibiotic in the first 30 days after hospital admission in non-ICU wards for CAP. The study was not powered to determine safety of shortening duration of antibiotic treatment. (NCT01964495).

Effects of nursing team communication and collaboration on treatment outcomes in intensive care unit patients with severe pneumonia.

Severe pneumonia is a common severe respiratory infection worldwide, and its treatment is challenging, especially for patients in the intensive care unit (ICU). To explore the effect of communication and collaboration between nursing teams on the treatment outcomes of patients with severe pneumonia in ICU. We retrospectively analyzed 60 patients with severe pneumonia who were treated at the ICU of the hospital between January 1, 2021 and December 31, 2023. We compared and analyzed the respiratory mechanical indexes [airway resistance (Raw), mean airway pressure (mPaw), peak pressure (PIP)], blood gas analysis indexes (arterial oxygen saturation, arterial oxygen partial pressure, and oxygenation index), and serum inflammatory factor levels [C-reactive protein (CRP), procalcitonin (PCT), cortisol (COR), and high mobility group protein B1 (HMGB1)] of all patients before and after treatment. Before treatment, there was no significant difference in respiratory mechanics index and blood gas analysis index between 2 groups (P > 0.05). However, after treatment, the respiratory mechanical indexes of patients in both groups were significantly improved, and the improvement of Raw, mPaw, plateau pressure, PIP and other indexes in the combined group after communication and collaboration with the nursing team was significantly better than that in the single care group (P < 0.05). The serum CRP and PCT levels of patients were significantly decreased, and the difference was statistically significant compared with that of nursing group alone (P < 0.05). The levels of serum COR and HMGB1 before and after treatment were also significantly decreased between the two groups. The communication and collaboration of the nursing team have a significant positive impact on respiratory mechanics indicators, blood gas analysis indicators and serum inflammatory factor levels in the treatment of severe pneumonia patients in ICU.

Comparative Analysis of C-reactive Protein and Procalcitonin as Biomarkers for Prognostic Assessment in Pediatric Sepsis.

Background Sepsis poses a critical medical challenge due to its profound systemic inflammatory response, which frequently results in organ dysfunction and high mortality rates, especially in pediatric patients. The condition requires prompt recognition and aggressive management to mitigate its severe outcomes. Methods This prospective study enrolled 248 pediatric patients admitted with sepsis to the pediatric intensive care unit (PICU) at our tertiary care center. Patients were randomly assigned to either the C-reactive protein (CRP) or procalcitonin (PCT) groups, with biomarker levels measured upon admission (hour zero) and again at 72 hours post-admission. Clinical parameters such as the need for ionotropic support, use of steroids, incidence of acute kidney injury (AKI), requirement for invasive ventilation, patient outcomes, and changes in antibiotic management were assessed based on these biomarker levels. Results Procalcitonin-positive sepsis cases demonstrated notable clinical severity compared to their C-reactive protein counterparts, showing significantly lower systolic blood pressure (p = 0.012), heightened need for ionotropic support (p < 0.0001), and more pronounced liver and renal dysfunction as indicated by elevated serum bilirubin (p = 0.001) and creatinine levels (p = 0.0058). The incidence of AKIwas also higher in procalcitonin-positive cases. Despite these severe clinical parameters, there were no significant differences in the length of the PICU stay or in patient outcomes concerning discharge and mortality rates. Procalcitonin levels effectively guided antibiotic management, resulting in therapy adjustments in a substantial proportion of cases, with 67 (54%) experiencing downgrades and 33 (27%) requiring upgrades based on procalcitonin levels measured 72 hours post-admission. Conclusion Procalcitonin proves to be a valuable biomarker in assessing the severity and management of sepsis in pediatric patients. It correlates significantly with clinical parameters such as blood pressure, the need for ionotropic support, and markers of organ dysfunction.

Association of antibiotics with the outcomes in COVID-19 pneumonia patients with elevated PCT levels

ObjectiveTo assess antibiotics impact on outcomes in COVID-19 pneumonia patients with varying procalcitonin (PCT) levels. MethodsThis retrospective cohort study included 3665 COVID-19 pneumonia patients hospitalized at five Mayo Clinic sites (March 2020 to June 2022). PCT levels were measured at admission. Patients’ antibiotics use and outcomes were collected via the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry. Patients were stratified into high and low PCT groups based on the first available PCT result. The distinction between high and low PCT was demarcated at both 0.25 ng/ml and 0.50 ng/ml. ResultsOur cohort consisted of 3665 patients admitted with COVID-19 pneumonia. The population was predominantly male, Caucasian and non-Hispanic. With the PCT cut-off of 0.25 ng/ml, 2375 (64.8 %) patients had a PCT level <0.25 ng/mL, and 1290 (35.2 %) had PCT ≥0.25 ng/ml. While when the PCT cut off of 0.50 ng/ml was used we observed 2934 (80.05 %) patients with a PCT <0.50 ng/ml while 731(19.94 %) patients had a PCT ≥0.50 ng/ml. Patients with higher PCT levels exhibited significantly higher rates of bacterial infections (0.25 ng/ml cut-off: 4.2 % vs 7.9 %; 0.50 ng/ml cut-off: 4.6 % vs 9.2 %).Antibiotics were used in 66.0 % of the cohort. Regardless of the PCT cutoffs, the antibiotics group showed increased hospital length of stay (LOS), intensive care unit (ICU) admission rate, and mortality. However, early de-escalation (<24 h) of antibiotics correlated with reduced hospital LOS, ICU LOS, and mortality. These results were consistent even after adjusting for confounders. ConclusionOur study shows a substantial number of COVID-19 pneumonia patients received antibiotics despite a low incidence of bacterial infections. Therefore, antibiotics use in COVID pneumonia patients with PCT <0.5 in the absence of clinical evidence of bacterial infection has no beneficial effect.

Cost-effectiveness analysis of procalcitonin and lung ultrasonography guided antibiotic prescriptions in primary care.

Antimicrobial resistance comes with high morbidity and mortality burden, and ultimately high impact on healthcare and social costs. Efficient strategies are needed to limit antibiotic overuse. This paper investigates the cost-effectiveness of testing patients with lower respiratory tract infection with procalcitonin, either at the point-of-care only or combined with lung ultrasonography. These diagnostic tools help detect the presence of bacterial pneumonia, guiding prescription decisions. The clinical responses of these strategies were studied in the primary care setting. Evidence is needed on their cost-effectiveness. We used data from a cluster-randomized bi-centric clinical trial conducted in Switzerland and estimated patient-level costs using data on resource use to which we applied Swiss tariffs. Combining the incremental costs of the two strategies and the reduction in the 28-days antibiotic prescription rate (APR) compared to usual care, we calculated Incremental Cost-Effectiveness Ratios (ICER). We also used the Cost-Effectiveness Acceptability Curve as an analytical decision-making tool. The robustness of the findings is ensured by Probabilistic Sensitivity Analysis and scenario analysis. In the base case scenario, the ICER compared to usual care is $2.3 per percentage point (pp) reduction in APR for the procalcitonin group, and $4.4 for procalcitonin-ultrasound combined. Furthermore, we found that for a willingness to pay per patient of more than $2 per pp reduction in the APR, procalcitonin is the strategy with the highest probability to be cost-effective. Our findings suggest that testing patients with respiratory symptoms with procalcitonin to guide antibiotic prescription in the primary care setting represents good value for money.

Prognostic value of pretreatment procalcitonin and neutrophil–lymphocyte ratio in extensive-stage small-cell lung cancer

ABSTRACT Background To investigate the influence of pretreatment neutrophil-to-lymphocyte ratio (NLR) and procalcitonin (PCT) on progression-free survival (PFS) in extensive-stage small-cell lung cancer (SCLC) patients. Method A total of 100 extensive-stage SCLC patients were enrolled in our study. Patients were stratified according to the median values of pretreatment NLR and PCT levels: low NLR group (NLR ≤3.17), high NLR group (NLR＞3.17), low PCT group (PCT ≤0.06; ng/ml), high PCT group (PCT＞0.06; ng/ml). The Kaplan-Meier method and multivariable Cox regression model were used to reveal the prognostic effects of pretreatment NLR and PCT on PFS. Results The median PFS of the total extensive-stage SCLC patients was 6.0 months. The median PFS of low pretreatment NLR group (NLR ≤3.17) was not significantly different from that of high pretreatment NLR group (6.2 months vs 5.8 months; p = .675). Patients with low pretreatment PCT (PCT ≤0.06; ng/ml) had significantly better PFS than patients with high pretreatment PCT (PCT＞0.06; ng/ml) (6.9 months vs 5.7 months; p = .043). With the multivariable Cox regression analysis, the response to first-line chemotherapy (p ≤ .001) and pretreatment PCT (HR = 0.516; 95%CI 0.326–0.817; p = .005) were identified as independent factors associated with PFS. Conclusion Pretreatment PCT is an independent factor associated with PFS in extensive-stage SCLC patients treated with first-line chemotherapy, but pretreatment NLR reflects no significant prognostic value in our study.

148. Antibiotic duration for lower respiratory tract infections with and without procalcitonin monitoring: a propensity score matched cohort across an integrated healthcare network

Abstract Background Clinical trials have shown that procalcitonin (PCT) testing is efficacious in reducing antibiotic duration, but it is not known whether the test is also effective in routine clinical practice. The goal of this study was to evaluate whether PCT use in patients with lower respiratory tract infections (LRTI) was associated with shorter antibiotic duration. Methods We performed a retrospective cohort study across Veterans Affairs acute care hospitals that were ordering PCT with some degree of frequency between January 2018 and December 2021 and included patients with LRTI (acute exacerbations of COPD and pneumonia) that lacked complicating factors (Figure 1). The primary outcome was length of antibiotic therapy. We used 1:1 nearest neighbor propensity score matching to estimate the difference in the primary outcome between PCT-tested and non-tested patients. Patients were fixed matched on hospital site and admission date, and propensity scores were calculated using a logistic regression model that included demographics, ward location, infection type, comorbidities, severity of illness, and antibiotic class. Figure 1. Flow diagram of patient selection based on inclusion and exclusion criteria Results Eighty-one (65%) VA hospitals had on-site PCT testing; all 81 sites had a pharmacist devoting at least some time to antibiotic stewardship activities. Of the 35,610 admissions that met inclusion criteria, 6,015 (17%) had ≥ 1 PCT test at least 48 hours into their antibiotic course (Table 1); in these patients, the median number of PCT tests checked was 2 (interquartile range, 1-3). Using propensity scores, 3,903 patients in the PCT group were matched to 3,903 patients in the no PCT group: the length of therapy was higher in the PCT group compared to the no PCT group with median of 8 days (IQR 6-11) compared to 7 days (IQR 5-10) and mean difference of 0.4 days (p&amp;lt; 0.01, Table 2). Conclusion In this retrospective propensity-matched cohort of patients with LRTI across 81 hospitals, we failed to demonstrate shorter antibiotic duration for patients who underwent PCT testing compared to those who did not. While our findings suggest that PCT use may not be effective for reducing antibiotic duration for LRTI under real-life circumstances, it is unclear if the PCT test was optimally implemented at these sites and whether other stewardship activities may have minimized the test's overall impact. Disclosures Daniel J. Livorsi, MD, Merck: Grant/Research Support

Procalcitonin Monitoring and Antibiotic Duration in Presumed Lower Respiratory Tract Infections: A Propensity Score-Matched Cohort Across the Veterans Health Administration.

Randomized controlled trials have shown that procalcitonin-guided algorithms can reduce antibiotic duration for lower respiratory tract infections (LRTIs). The goal of this study was to compare antibiotic duration for LRTIs with and without procalcitonin testing in real-life practice. This retrospective cohort study included all acute care hospital admissions for presumed LRTIs between 1/2018 and 12/2021 at 81 Veterans Affairs facilities with on-site procalcitonin testing. The exposure was procalcitonin testing; the primary outcome was antibiotic duration. We used 1:1 nearest-neighbor propensity score matching to estimate the difference in outcome between procalcitonin-tested and nontested patients. A total of 35 610 patients with LRTIs were included (6015 [16.9%] with procalcitonin testing; 29 595 [83.1%] without testing). In tested patients, the median number of procalcitonin levels checked (interquartile range) was 2 (1-3). The mean antibiotic duration was 10.0 days in the procalcitonin group compared with 8.3 days in nontested patients (unadjusted difference, 1.7 days; P < .0001). After propensity score matching with 3903 pairs, antibiotic duration remained greater in the procalcitonin group (9.6 days vs 9.2 days; P < .0001). In a subgroup analysis of 2241 tested patients with a procalcitonin value at the standard threshold for antibiotic discontinuation, antibiotic duration was shorter in tested vs nontested patients, with a mean difference of 0.1 days (P < .01). In this retrospective propensity-matched cohort of patients with presumed LRTIs across a geographically diverse group of hospitals, patients who underwent procalcitonin testing did not have a meaningful reduction in antibiotic duration compared with those who were not tested. Poor implementation of procalcitonin testing may have undermined its effectiveness.

Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival—a systematic review and meta-analysis

BackgroundAppropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients.MethodsWe searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes.ResultsWe included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD − 1.79 days, 95% CI: -2.65, − 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD − 0.67 days 95% CI: − 1.76, 0.41 and MD − 1.23 days, 95% CI: − 3.13, 0.67, respectively).ConclusionsPCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.Graphical abstract

Role of Procalcitonin, C-reactive Protein and Total Leucocyte Count in Suspected Cases of Sepsis

Background: Sepsis is a life-threatening infection, responsible for tremendous morbidity, mortality and healthcare expenditure worldwide. Sepsis is characterized by non-specific symptoms and clinical diagnosis remains difficult. C Reactive protein (CRP) and procalcitonin (PCT) are now days used as surrogate markers of sepsis. Aim: To determine PCT levels in patients with suspected sepsis and its correlation with CRP and total leucocyte count (TLC). Material &amp; Methods: The retrospective study was conducted in tertiary care hospital in India. Adults patients (&gt; 18 years) admitted to Intensive care unit in the hospital during study period, fulfilling the ACCP criterion for the diagnosis of sepsis were included in the study. Data was collected using laboratory software maintaining confidentiality. Results: The study comprised of 190 patients. Patients were divided into four groups based on PCT values and severity of sepsis. Out of 190 patients, PCT was positive in 135 patients. The CRP and TLC levels were distributed into the four PCT groups and their correlation with PCT was studied. For PCT values between 2-10ng/ml, &gt;10ng/ml CRP showed statistically significant correlation with p value &lt;0.05, whereas correlation of TLC with PCT was poor. Conclusion Procalcitonin along with CRP is a better diagnostic tool for sepsis but their correlation in context to TLC was poor. Due to lack of an ideal isolated marker, our study mandates multidisciplinary approach for diagnosis of sepsis. Keywords: Sepsis, Procalcitonin, C reactive protein, Total leucocyte count, Culture

Procalcitonin to reduce exposure to antibiotics and individualise treatment in hospitalised old patients with pneumonia: a randomised study

BackgroundTreating pneumonia in old patients remains challenging for clinicians. Moreover, bacterial antimicrobial resistance is a major public health threat.ObjectiveThe PROPAGE study evaluated the interest of a strategy using serial measurements of procalcitonin (PCT) to reduce the duration of antibiotic therapy in old patients with pneumonia.MethodsPROPAGE took place from Dec.-2013 to Jun.-2016 in eight French geriatric units. It was a prospective, comparative, randomised, open-label study involving old patients (≥ 80 years) who had initiated antibiotic treatment for pneumonia in the previous 48 h. PCT was monitored in all patients and two decision-making PCT-based algorithms guided antibiotic therapy in patients from the PCT group.Results107 patients were randomised (PCT, n = 50; Control, n = 57). Antibiotic therapy exposure was reduced in the PCT group as compared to the Control group (median duration of antibiotic therapy, 8 vs. 10 days [rank-test, p = 0.001]; antibiotic persistence rates on Days 6 and 8, 54% and 44% vs. 91% and 72%) and no significant difference was found in recovery rate (84% vs. 89.5%; Pearson Chi² test, p = 0.402).ConclusionAlthough, the superiority of the strategy was not tested using a composite criterion combining antibiotic therapy duration and recovery rate was not tested due to the small sample size, the present study showed that monitoring associated with PCT-guided algorithm could help shorten antibiotic treatment duration in the very old patients without detrimental effects. Measuring PCT levels between Day 4 and Day 6 could be helpful when making the decision regarding antibiotic discontinuation.Trial registrationNCT02173613. This study was first registered on 25/06/2014.

The Association between Admission Procalcitonin Level and The Severity of COVID-19 Pneumonia: A Retrospective Cohort Study.

Background and Objectives: An elevated procalcitonin level has classically been linked to bacterial infections. Data on the association between elevated procalcitonin and the outcome of coronavirus disease 2019 (COVID-19) are conflicting. Some linked it to associated bacterial co-infections, while others correlated the elevation with disease severity without coexisting bacterial infections. We aimed to investigate the association between high procalcitonin and the severity of COVID-19. Materials and Methods: Hospitalized patients with confirmed COVID-19 pneumonia were divided into two groups: the normal-procalcitonin group and the high-procalcitonin group (>0.05 ng/mL). Patients with concomitant bacterial infections on admission were excluded. The primary outcomes were the need for intensive care unit (ICU) admission, progression to invasive mechanical ventilation (IMV), and in-hospital 28-day mortality. Results: We included 260 patients in the normal procalcitonin group and 397 patients in the high procalcitonin group. The mean age was 55 years and 49% were females. A higher number of patients in the elevated procalcitonin group required ICU admission (32.7% vs. 16.2%, p < 0.001) and IMV (27.2% vs. 13.5%, p < 0.001). In-hospital mortality was significantly higher in the elevated procalcitonin group (18.9% vs. 8.5%, p < 0.001). After adjusting for other covariates, procalcitonin > 0.05 ng/mL was an independent predictor of progression to IMV (OR, 1.71; 95% CI, 1.08–2.71; p = 0.022), ICU admission (OR, 1.73; 95% CI, 1.13–2.66; p = 0.011), and in-hospital mortality (OR, 1.99; 95% CI, 1.14–3.47; p = 0.015). An elevated procalcitonin level was the strongest predictor of in-hospital mortality. Conclusions: Measurement of procalcitonin can have a prognostic role among COVID-19 patients. The admission procalcitonin level can identify patients at risk of ICU admission, progression to IMV, and in-hospital mortality.

Evaluation of Procalcitonin's Utility to Predict Concomitant Bacterial Pneumonia in Critically Ill COVID-19 Patients.

Background: Historically, procalcitonin(PCT) has been used as a predictor of bacterial infection and to guide antibiotic therapy in hospitalized patients. The purpose of this study was to determine PCT's diagnostic utility in predicting secondary bacterial pneumonia in critically ill patients with severe COVID-19 pneumonia. Methods: A retrospective cohort study was conducted in COVID-19 adults admitted to the ICU between March 2020, and March 2021. All included patients had a PCT level within 72 h of presentation and serum creatinine of <1.5mg/dL. A PCT threshold of 0.5ng/mL was used to compare patients with high( ≥ 0.5ng/mL) versus low(< 0.5ng/mL) PCT. Bacterial pneumonia was defined by positive respiratory culture. A receiver operating characteristics (ROC) curve was utilized to evaluate PCT as a diagnostic test for bacterial pneumonia, with an area under the curve(AUC) threshold of 0.7 to signify an accurate diagnostic test. A multivariable model was constructed to identify variables associated with in-hospital mortality. Results: There were 165 patients included: 127 low PCT versus 38 high PCT. There was no significant difference in baseline characteristics, vital signs, severity of disease, or outcomes among low versus high PCT groups (all p > 0.05). While there was no difference in bacterial pneumonia in low versus high groups (34(26.8%) versus 12(31.6%), p = 0.562), more patients in the high PCT group had bacteremia (19(15%) versus 11(28.9%), p = 0.050). Sensitivity was 26.1% and specificity was 78.2% for PCT to predict bacterial pneumonia coinfection in ICU patients with COVID-19 pneumonia. ROC yielded an AUC 0.54 (p = 0.415). After adjusting for LDH>350U/L and creatinine in multivariable regression, PCT did not enhance performance of the regression model. Conclusions: PCT offers little to no predictive utility in diagnosing concomitant bacterial pneumonia in critically ill patients with COVID-19 nor in predicting increased severity of disease or worse outcomes including mortality.

COST ANALYSIS FOR USE OF PROCALCITONIN AND INFLAMMATORY MARKERS IN COVID-19 VENTILATOR-ASSOCIATED PNEUMONIA

TYPE: Abstract TOPIC: Chest Infections PURPOSE: Procalcitonin has been used to differentiate between bacterial infections and other inflammatory processes in COVID-19. The goal of this study is to observe if procalcitonin use is associated with decreased duration of antibiotics and potential cost savings. Additionally, secondary objectives include if procalcitonin use is associated with ventilator changes, inflammatory markers, and mortality. METHODS: In this retrospective study, 287 patient records were selected based on the diagnosis of positive SARS-CoV-2 by PCR test and patients requiring mechanical ventilation. Lab values were obtained based on ventilator associated events (VAE) or sputum collections. RESULTS: There was no significant difference in those who received antibiotics between the procalcitonin cohort and non-procalcitonin cohort. The average duration of antibiotics was not statistically significant for vancomycin (2.2d v 1.8d), piperacillin-tazobactam (5.6d v 4d), azithromycin (2.7d v 2.5d), or meropenem (3d v 3.3d), between the procalcitonin and non-procalcitonin groups, respectively. Secondary outcomes were similarly not significant for ventilator changes and inflammatory markers. Lactic acid was lower in the procalcitonin group (1.8 v 3,1, p=0.01) along with overall 30-day mortality (45% v 76%, p=0.02). CONCLUSIONS: The use of procalcitonin did not have a significant correlation with duration of antibiotic use, ventilator changes, or inflammatory markers. Overall, the cost of inflammatory markers was approximated to be $377 daily, without reduction of antibiotic usage. CLINICAL IMPLICATIONS: The use of procalcitonin did not reduce antibiotic usage in the setting of COVID-19 ventilator-associated pneumonia and results in greater costs. DISCLOSURE: Nothing to declare. KEYWORD: procalcitonin

Role of procalcitonin as a predictor of clinical outcomes in hospitalized patients with COVID-19

ObjectivesIn this study, we aimed to determine the correlation between procalcitonin (PCT) levels and clinical outcomes including in-hospital mortality, intensive care unit (ICU) length of stay, and hospital length of stay in patients hospitalized with COVID-19. MethodsClinical, laboratory, and demographic data of 223 patients who met inclusion criteria were analyzed. PCT measurements of 0.25 ng/mL and 0.50 ng/mL were used to stratify patients into 2 mutually exclusive groups. ResultsPatients with PCT above 0.25 ng/mL on admission had significantly elevated Acute Physiology and Chronic Health Evaluation II scores (9 vs 8; P = 0.042) and C-reactive proteins levels (111 μg/mL vs 79 μg/mL; P = 0.007). A multivariable binary logistic regression model demonstrated no relationship between PCT and mortality (OR = 1.00; 95% Cl: 0.97 to 1.02; P = 0.713). Kaplan-Meier analysis revealed no statistical evidence of a difference between PCT groups and hospital length of stay (P = 0.144 for 0.25 ng/mL, P = 0.368 for 0.50 ng/mL) or intensive care unit length of stay (P = 0.986 for 0.25 ng/mL, P = 0.771 for 0.50 ng/mL). ConclusionsElevated PCT levels were associated with severity of illness but did not correlate with in-hospital mortality, hospital length of stay, or ICU length of stay.

The Procalcitonin-guided Antibiotics in Respiratory Infections (PARI) project in general practice \u2013 a study protocol

BackgroundAntibiotic resistance is a global health challenge and the close correlation between antibiotic use and the development of resistance makes it essential to maintain a rational use of antibiotics. Most antibiotics are prescribed in general practice against acute respiratory tract infections (ARTI), even though most of these infections are of viral etiology. Thus, a safe method to substantially reduce unnecessary use of antibiotics in general practice is needed. Procalcitonin (PCT) is a precursor protein with very low circulating levels in the blood under physiological conditions. However, in response serious bacterial infection the level of PCT in the blood may increase significantly. Until recently, quantitative analyses of PCT was performed in hospital laboratories, impeding the implementation of PCT in primary care. Our aim is to determine whether it is possible to lower the use of antibiotics in patients presenting with symptoms of ARTI, without significantly prolonging the period of illness, by using a newly released PCT point-of-care test in general practice.MethodsThe Procalcitonin-Guided Antibiotics in Respiratory Infections (PARI) study is a randomized, single-blinded, non-inferiority, multi-practice intervention study comparing a PCT-group to a control group. Patients (N = 508) will be randomly assigned 1:1 to standard care or to the PCT group. The primary outcomes the duration of illness and symptoms from ARTI measured with the Acute Respiratory Tract Infection Questionnaire. Secondary outcomes include (1) Number of participants in each trial arm exposed to antibiotic treatment at index consultation (day 1) and within 30 days, (2) Number of participants in each trial arm with side effects from antibiotic treatment within 14 days, (3) Number of participants in each trial arm with re-consultations within 30 days, (4) Number of participants in each trial arm admitted to hospital (including diagnosis and mortality) within 30 days, (5) Characterization of biomarker (CRP and PCT) level at index consultation. Tertiary outcomes include patient and general practitioner satisfaction with the use of the PCT point-of-care test, and long-term follow-up.DiscussionTo our knowledge, this is the first study to examine a PCT point-of-care test in general practice with the aim of reducing the use of antibiotics in patients with symptoms of ARTI. Results of this study may prove important in targeting antibiotic treatment only to those patients who need it, thus contributing to limiting the spread of antibiotic resistance.Trial registrationClinicalTrials.gov Identifier: NCT04216277, date of registration: 2. of January 2020.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Antibiotic stewardship: Early discontinuation of antibiotics based on procalcitonin level in COVID-19 pneumonia.

Procalcitonin (PCT) levels rise in systemic inflammation, especially if bacterial in origin. COVID-19, caused by the novel coronavirus SARS-CoV-2, presents with acute respiratory distress syndrome. Elevated procalcitonin in COVID-19 is considered as a marker for severity of disease. There is no study available that indicates whether elevated PCT in COVID-19 is associated with inflammation or superimposed bacterial infection. The objective of this study is to evaluate the association between PCT levels and superadded bacterial infection, and the effect of discontinuation of antibiotic in the low PCT (<0.25ng/ml) group on patients' outcomes. A retrospective chart review of patients admitted with COVID-19 pneumonia at a single tertiary care centre. We collected information on demographics, co-morbidities, PCT level, antibiotic use, culture results for bacterial infection, hospital length of stay (LOS) and mortality. Continuous variables were summarized with the sample median, interquartile range, mean and range. Categorical variables were summarized with number and percentage of patients. We studied a total of 147 patients with COVID-19 pneumonia. 101 (69%) patients had a low PCT level (< 0.25ng/ml). Bacterial culture results were negative for all patients, except 1 who had a markedly elevated PCT level (141.ng/ml). In patients with low PCT, 42% received no antibiotics, 59% received antibiotics initially, 32 (57%) patients antibiotic discontinued early (within 24hours) and their culture remained negative for bacterial infections during hospitalizations. LOS was shorter (6days in low PCT group compared to 9days) in high PCT group. LOS was 1day shorter (5days vs 6days) in no antibiotic group compared to antibiotic group. Our study examines the association between PCT level and superadded bacterial infection in COVID-19 pneumonia. Our results demonstrate that most patients admitted with COVID-19have a low PCT (<0.25ng/ml), which suggests no superadded bacterial infection and supports the previously published literature regarding low PCT in viral pneumonia. Procalcitonin level remains low in the absence of bacterial infection. Early de-escalation/discontinuation of antibiotics is safe without adverse outcomes in COVID-19 pneumonia. Early de-escalation/discontinuation of antibiotics is associated with lower LOS.

Impact on antimicrobial consumption of procalcitonin-guided antibiotic therapy for pneumonia/pneumonitis associated with aspiration in comatose mechanically ventilated patients: a multicenter, randomized controlled study

BackgroundIn comatose patients receiving oro-tracheal intubation for mechanical ventilation (MV), the risk of aspiration is increased. Aspiration can lead to chemical pneumonitis (inflammatory reaction to the gastric contents), or aspiration pneumonia (infection caused by inhalation of microorganisms). Distinguishing between the two types is challenging. We tested the interest of using a decisional algorithm based on procalcitonin (PCT) values to guide initiation and discontinuation of antibiotic therapies in intubated patients.MethodsThe PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial is a multicenter, prospective, randomized, controlled, single-blind, superiority study comparing two strategies: (1) an intervention group where threshold PCT values were used to guide initiation and discontinuation of antibiotics (PCT group); and (2) a control group, where antibiotic therapy was managed at the physician’s discretion. Patients aged 18 years or over, intubated for coma (Glasgow score ≤ 8), with MV initiated within 48 h after admission, were eligible. The primary endpoint was the duration of antibiotic treatment during the first 15 days after admission to the ICU.ResultsFrom 24/2/2015 to 28/8/2019, 1712 patients were intubated for coma in the 5 participating centers, of whom 166 were included in the study. Data from 159 were available for intention-to-treat analysis: 81 in the PCT group, and 78 in the control group. Overall, 67 patients (43%) received antibiotics in the intensive care unit (ICU); there was no significant difference between groups (37 (46%) vs 30 (40%) for PCT vs control, p = 0.432). The mean duration of antibiotic treatment during the first 15 days in the ICU was 2.7 ± 3.8 days; there was no significant difference between groups (3.0 ± 4.1 days vs 2.3 ± 3.4 days for PCT vs control, p = 0.311). The mean number of days under MV was significantly higher in the PCT group (3.7 ± 3.6 days) than in controls (2.7 ± 2.5 days, p = 0.033). The duration of ICU stay was also significantly longer in the PCT group: 6.4 ± 6.5 days vs 4.6 ± 3.5 days in the control group (p = 0.043). After adjustment for SAPS II score, the difference in length of stay and duration of mechanical ventilation between groups was no longer significant.ConclusionThe use of PCT values to guide therapy, in comparison to the use of clinical, biological (apart from PCT) and radiological criteria, does not modify exposure to antibiotics in patients intubated for coma.Trial registration Clinicaltrials.gov Identifier NCT02862314.

PROCALCITONIN AS A PREDICTOR OF CLINICAL OUTCOMES IN PATIENTS WITH COVID-19

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: The purpose of this study was to retrospectively determine if elevated procalcitonin (PCT) in patients hospitalized with COVID-19 was associated with increased in-hospital mortality, intensive care unit (ICU) length of stay, or hospital length of stay. METHODS: We collected data on 402 adult patients with positive COVID-19 PCR testing admitted to hospitals within our health system from March 1, 2020 until July 10, 2020. Patient characteristics including age, tobacco use, coronary artery disease, hypertension, chronic kidney disease, malignancy, vital signs on admission, PCT levels upon admission, peak PCT levels, and CT chest results were collected. Clinical outcomes including hospital length of stay, ICU length of stay, and in-hospital mortality were also obtained. A PCT measurement on admission of 0.25 ng/mL was used to stratify patients into two mutually exclusive groups. Comparisons of the two groups were made with Mann-Whitney for continuous variables and Chi-square or Fisher’s exact test based on expected frequencies. Multivariable binary logistic regression models were used to model mortality. Kaplan-Meier was used to examine potential differences in overall length of stay as well as ICU length of stay while considering death to be a censoring event. SAS v. 9.4 was used for all analyses;P < 0.05 was deemed significant. RESULTS: Results of the multivariable analysis demonstrated elevated PCT level on hospital admission was not associated with increased odds of mortality (OR = 1.00;95% Cl: 0.97 to 1.02;P = 0.713). Results of the Kaplan-Meier curve revealed no evidence of a significant difference between PCT groups for hospital length of stay (P = 0.144) or ICU length of stay (P = 0.260). Results from the mortality model demonstrated every additional ten years of age was associated with increased odds of mortality (OR = 2.42;95% CI: 1.59 to 4.09;P < 0.001) after adjusting for all other variables. Increased duration of mechanical ventilation was also associated with increased odds of mortality (OR = 2.67;95% CI: 1.52 to 5.10;P = 0.001). CONCLUSIONS: This retrospective study of patients hospitalized with COVID-19 demonstrated no evidence that elevated PCT levels on hospital admission were associated with increased in-hospital mortality, ICU length of stay, or hospital length of stay. CLINICAL IMPLICATIONS: Further studies are needed to fully assess the use of PCT in COVID-19 patients as a prognostic biomarker to predict mortality and other clinical outcomes. DISCLOSURES: No relevant relationships by Ali Aldamen, source=Web Response No relevant relationships by Sarah Aurit, source=Web Response No relevant relationships by Chris Destache, source=Web Response No relevant relationships by Ian Jackson, source=Web Response No relevant relationships by Hadi Jaradeh, source=Web Response No relevant relationships by Shraddha Narechania, source=Web Response No relevant relationships by Manasa Velagapudi, source=Web Response