using procalcitonin to care for hospitalized patients hospitalist best practice j rush pierce jr,...

Using procalcitonin to care for hospitalized patients

Hospitalist Best PracticeJ Rush Pierce Jr, MD, MPH

Division of Hospital MedicineJuly 22, 2015

Roadmap for today

•Illustrative cases•Procalcitonin: what it is and why it might work•Evidence for usefulness of procalcitonin in settings of specific interest to hospitalists•Availability and cost•Use of Procalcitonin – possible clinical algorithms•Discussion with specialists and experts

07/24/2014 Using procalcitonin to care for hospitalized patients 2

Disclosures

• Financial: none• Biases:

– Evidence should inform our thinking

– Local variation is an interesting part of life

– Medicine is fun


Case 1• 64 y/o man with DM, HTN, HFpEF admitted

with 1 wk of increased SOB, cough, gray sputum and chills. Exam: T = 37.5, JVD, rales at right base and trace edema. WBC = 13,000, BNP = 800. CXR shows “peribronchial cuffing & reticular opacities could represent developing pneumonia vs. interstitial edema, clinical correlation advised”

07/24/2014 4Using procalcitonin to care for hospitalized patients

Clinical questions

1. Does this patient have a respiratory infection, CHF or both?

2. Should I order antibiotics on admission?3. Should he go home on antibiotics?


Case 2• 83 y/o woman with dementia at SNF recovering

from hip fx, adm to MICU looking dry with BP = 80, acute delirium and AKI. WBC = 14,000, lactate = 4.5, 35 WBC’s in urine on admission and CXR with right lower lobe opacities c/w atelectasis vs possible aspiration. Put on Unasyn and vanc, volume resuscitated. Blood, urine cultures neg, CXR about same, now being transferred to floor.


Clinical questions

1. Did this patient have severe sepsis due to an infection, or delirium precipitated by volume depletion without infection?

2. Should I continue antibiotics now?3. Should she go back to the SNF on antibiotics?


Procalcitonin: what it is and why it might work


Procalcitonin• Calcitonin – a hormone seeking a job

– Produced by parafollicular cells in thyroid– Opposes effect of PTH, inhibits osteoclasts,

stimulates osteoblasts– No known pathologic state associated with deficiency

• Procalcitonin– precursor molecule processed by parafollicular cells

to calcitonin– Undetectable in normal state


Calcitonin


Source: Muller B: Swiss Med Wkly 2001:131:595

Procalcitonin in sepsis

• Rises dramatically with bacterial infections, but very little with viral infections

• Rarely rises in sepsis due to non-infectious origin

• Peak levels correlates with prognosis• Levels fall when bacterial infection treated• Not affected by immune suppression• Half-life 25 – 30 hours


Procalcitonin and sepsis prognosis


Source: Jensen J: Crit Care Med 2006;34:2596

Why procalcitonin might be useful

• Diagnosis of infection is often difficult– Clinical tools have significant limitations– Specific etiology often elusive (sepsis <50%, CAP

<30%)

• Antimicrobial use has its downsides– Key driver to antibiotic resistance– Can be associated with adverse reactions– Major risk factor for C difficele– Often costly


Evidence for usefulness of procalcitonin in settings of

specific interest to hospitalists


ProHOSP Trial

• Prospective randomized controlled trial; 6 ED’s in Switzerland, 2006 - 2008

• 1359 pts presenting with possible LRTI (CAP, bronchitis, exacerbation of COPD)

• Initiation and continuation of antibiotic based on clinician judgment vs PCT algorithm

• IN PCT algorithm arm, clinician could overrule for specific indication


Source: Schuetz P: JAMA 2009;302:1059

ProHOSP Trial - conclusions

• In patients with LRTIs, a strategy of PCT guidance compared with standard guidelines resulted in – similar rates of adverse outcomes, as well as – lower rates of antibiotic exposure– lower rates of antibiotic-associated adverse

effects.



PRORATA Trial

• Prospective randomized controlled trial; 5 ICU’s in France, 2007 - 2008

• 621 pts adm to ICU with suspected sepsis • Initiation and continuation of antibiotic based

on clinician judgment vs PCT algorithm• IN PCT algorithm arm, clinician could overrule

for specific indication


Source: Bouadma L: Lancet 2010;375:463

PRORATA Trial - Conclusions

• A procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical patients in intensive care units could reduce antibiotic exposure and selective pressure with no apparent adverse outcomes.



BACH Trial

• International multicenter cohort study, 2007 - 2008

• 1641 patients presenting to ED with dyspnea and acute heart failure (AHF) was diagnostic consideration

• Signs, sxs, lab, markers including PCT• 30, 60, 90 day mortality


Source: Maisal A: European J Heart Failure 2012;14, 278

BACH Trial - Conclusions

• Procalcitonin may aid in the diagnosis of pneumonia, particularly in cases with high diagnostic uncertainty.

• PCT may aid in the decision to administer antibiotic therapy to patients presenting with AHF in which clinical uncertainty exists regarding a superimposed bacterial infection.



Meta-analysis of PCT use


Source: Schuetz P: Arch Intern Med 2011;171:1322


Source: Schuetz P: Arch Intern Med 2011;171:1322

Case 1• 64 y/o man with DM, HTN, HFpEF admitted

with 1 wk of increased SOB, cough, gray sputum and chills. Exam: T = 37.5, JVD, rales at right base and trace edema. WBC = 13,000, BNP = 800. CXR shows “peribronchial cuffing & reticular opacities could represent developing pneumonia vs. interstitial edema, clinical correlation advised”


Clinical questions

1. Does this patient have a respiratory infection, CHF or both?

2. Should I order antibiotics on admission?3. Should he go home on antibiotics?


Case 2• 83 y/o woman with dementia at SNF recovering

from hip fx, adm to MICU looking dry with BP = 80, acute delirium and AKI. WBC = 14,000, lactate = 4.5, 35 WBC’s in urine on admission and CXR with right lower lobe opacities c/w atelectasis vs possible aspiration. Put on Unasyn and vanc, volume resuscitated. Blood, urine cultures neg, CXR about same, now being transferred to floor.


Clinical questions

1. Did this patient have severe sepsis due to an infection, or delirium precipitated by volume depletion without infection?

2. Should I continue antibiotics now?3. Should she go back to the SNF on antibiotics?


Availability and cost of procalcitonin at UNMH

• Currently sent out to ARUP Reference Lab– FedEx afternoons Mon – Fri to ARUP, run next

day, reported within 24 hrs– 3 to 5 day turnaround

• Charge = $471.60


Use of Procalcitonin – possible clinical algorithms



Source: Schuetz P: BMC Medicine 2011;9:107

Discussion with specialists and experts

• Should we advocate for POC PCT testing?• Should we use PCT to guide initiation and

continuation of antibiotic therapy for:– LRTI– Pts coming out of ICU on antibiotics

• Should we teach use of PCT to learners?


using procalcitonin to care for hospitalized patients hospitalist best practice j rush pierce jr,...

Documents

fun07242014using procalcitonin

usefulness of procalcitonin

hospitalized patientscase

parafollicular cells

respiratory infection

reticular opacities

interstitial edema

trace edema