Use of procalcitonin for rational use of antibiotics: ISCCM Guidelines
New Delhi: A recent article published in the Indian Journal of Critical Care Medicine reports guidelines for using Procalcitonin (PCT) for rational antibiotics use.
The rapid emergence of antibiotic resistance is a global problem that compromises the progress of humankind in encountering infections and saving lives. Factors contributing to increased infection with multidrug-resistant organisms include natural selection and adaptation of microbes, immunosuppression, ageing, immunosuppression misuse and overuse of antimicrobial agents. To encounter this problem, two main approaches have been suggested. The first is to invest in new antibiotic discoveries, and the second is the optimal use of antibiotics; the latter approach has been refined into a new concept called antibiotic stewardship.
Several meta-analyses and randomized trials have addressed using PCT for antibiotic stewardship in hospital-acquired and community-acquired infections. This guideline by the Indian Society of Critical Care Medicine (ISCCM) frames evidence-based recommendations for serum PCT in antibiotic stewardship for various infections.
The recommendations are as given below:
PCT in sepsis
Recommendations
- Baseline serum PCT levels may be done in patients with sepsis.
- Procalcitonin alone should not be used for the diagnosis of sepsis.
- The authors suggest that PCT be used to differentiate culture-negative sepsis from non-sepsis.
- Procalcitonin levels can be used to support the discontinuation or de-escalation of antibiotics in patients with sepsis.
- Procalcitonin levels may be repeated every 72 hours or earlier if clinically indicated.
- Procalcitonin levels of less than 0.5 ng/mL or a drop by more than 80% from baseline should be used with clinical judgment for decision-making regarding antibiotic de-escalation.
- Procalcitonin may be used to define the severity of infection in a patient with sepsis.
- Physicians should be aware of infections where PCT is not a reliable marker.
PCT in Lower Respiratory Tract Infections (LRTIs)
Recommendations
- Baseline PCT should not be routinely measured for initiating antibiotics in all patients with CAP (community-acquired pneumonia).
- Baseline PCT levels should be obtained in patients with severe CAP for subsequent de-escalation of antibiotics.
- If indicated, baseline serum PCT should preferably be measured at admission.
- Baseline PCT levels alone should not be used to withhold empiric antibiotic therapy in patients with LRTIs (PCT in lower respiratory tract infections), including CAP.
- Based on clinical judgment, prompt initiation of optimal empiric antibiotic therapy is recommended in patients with LRTIs, including CAP.
- Procalcitonin levels alone should not be used to differentiate between bacterial and viral etiology in patients with CAP.
- Procalcitonin should be used, along with clinical judgement, to take decisions regarding de-escalation in patients with CAP regarding antibiotics beyond 5–7 days.
- Procalcitonin levels of 0.5 ng/mL or a decline of 80% from baseline should be used for the de-escalation of antibiotics in severe CAP or patients requiring intensive care.
- Baseline PCT levels alone should not be used to make the clinical decision regarding antibiotic initiation in patients with VAP (ventilator-associated pneumonia) and HAP (hospital acquired pneumonia).
- Serial serum PCT level measurement, preferably every 48 hours, should be used in antibiotic de-escalation (UPP).
- Procalcitonin should be used as a part of an antibiotic stewardship program for antibiotic de-escalation in patients with VAP on antibiotics beyond 7 days.
- Procalcitonin levels of 0.5 ng/mL or a decline of 80% from baseline along with clinical criteria should be used for de-escalation in VAP and HAP.
- A decline of 80% or more from baseline and clinical criteria can be used for de-escalation if baseline values are available.
PCT in Other Infections
Recommendations
- Procalcitonin may be used to diagnose bacteremia in UTI (urinary tract infection) patients.
- The authors suggest against using PCT as a marker of treatment outcome in patients with febrile UTI.
- Procalcitonin alone should not be used to diagnose infection or spontaneous bacterial peritonitis (SBP) among patients with cirrhosis and end-stage liver disease.
- Procalcitonin may be considered for diagnosing infection or SBP in combination with clinical and other laboratory parameters.
- The authors recommend against the use of PCT for the diagnosis of acute severe pancreatitis.
- Procalcitonin alone should not be used for the diagnosis of SBP.
- Procalcitonin may be considered for diagnosing SBP in combination with clinical features.
- Serum PCT alone should not be used to diagnose infection in immunocompromised patients.
- Serum PCT should not be used to guide antibiotic therapy in immunocompromised patients.
