September - 2012
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Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients.Layios N, Lambermont B, Canivet JL, Morimont P, Preiser JC, Garweg C, Ledoux D, Frippiat F, Piret S, Giot JB, Wiesen P, Meuris C, Massion P, Leonard P, Nys M, Lancellotti P, Chapelle JP, Damas P. Critical Care Medicine, 2012, 40(8):2304-9 This page is only available to Crit-IQ subscribers. To view the rest of this review and gain access to our vast array of critical care teaching tools including podcasts, vodcasts, modules, exam preparation tools, teaching aids and much more, login here, or Become a Member to register |
September |
Previous Comments
| Procalcitonin has received immense interest as a tool to (1) differentiate between infectious and non infectious causes of sepsis, (2) Assess effectiveness of treatment, (3) Duration of treatment and (4) Antibiotic stewardship ( apparently has PC based treatment has shown 20-70% decline in antibiotic consumption without change in mortality). The studies however have been small (usually 50-70 subjects in each arm) and often in different settings - outpatient, inpatient-non-icu, ICU. Critically sick patients are altogether different group and the test which performs well outside icu may not be so good in these patients. Also the cut-offs for PC have been different. Although antibiotic stewardship has been shown to decrease antibiotic consumption without change in mortality the non-inferiority criteria in mortality used was 7-10%! The study showed non-significant increase in mortality of ~ 3.3% in PC group but it was heavily under powered! Ugarte H et al (Crit Care Med 1999;27:498–504) assessed PC in icu population back in 1999 and came out with dramatically low sens and spec of 67-61%. The metaanalysis done by colleagues in Napean, Penrith looking at PC in icu population, showed Overall, the diagnostic performance of procalcitonin was low, with mean values of both sensitivity and specificity being 71% and an area under the summary receiver operator characteristic curve of 0.78. There appeared to be a positive bias in smaller studies. This study has further reinforced the caution on PC in ICU population. Patients who are critically ill have altered inflammatory response, they are heterogeneous group, often have life threatening infections and often have resistant bugs. I am certainly sceptical about using a fixed value of procalcitonin to make treatment decisions in critically sick patients. | |
| Shivesh Prakash-30 Sep, 2012 12:44:28 PM | |
| There is a recent Cochrane meta-analysis on procalcitonin. It seems to suggest reduction of antibiotic usage, while no difference in mortality. Mixed groups as you say. http://bit.ly/W57kYm | |
| Jonno West-01 Oct, 2012 09:01:56 AM | |
Comment
Procalcitonin has long been haled as a marker that will transform antibiotic practice in ICU. Several trials have now studied the role of procalcitonin in a protocolised fashion and found evidence for its use, both for triggering initiation and de-escalation of antibiotic...