The Use of Procalcitonin to Improve Antibiotic …...8/11/18 1 The Use of Procalcitonin to Improve...
Transcript of The Use of Procalcitonin to Improve Antibiotic …...8/11/18 1 The Use of Procalcitonin to Improve...
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The Use of Procalcitonin to Improve Antibiotic
Stewardship
Patrick A. Laird, DNP, RN, ACNP-BC
Disclosures
I have no actual or potential conflict of interest in relation to this presentation.
Objectives
● Describe the pathophysiology of procalcitonin.● Cite advantages in using procalcitonin levels in patients
with bacterial infection and sepsis.● Discuss how the use of serial procalcitonin measurements
may improve antibiotic stewardship.
Background● First described in 1975
○ Precursor for calcitonin in chicken● 1981--demonstrated synthesis of calcitonin in humans● Currently more than 178 serum biomarkers for infection● Procalcitonin most extensively studied
(Vijayan et al., 2017) Figure 1: Chicken
Pathophysiology
● Protein consisting of 116 amino acids
● Peptide precursor of calcitonin
● Normally undetectable in healthy patients
Fig. 2 Procalcitonin: structure and synthesis
Pathophysiology
● Produced primarily by thyroid C-cells
● Also found in small amounts in neuroendocrine tissue
● High levels of cytokines and bacterial endotoxins cause increase in procalcitonin levels
Figure 3: Fate of Procalcitonin
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Pathophysiology
● Procalcitonin not induced in most viral infections● Some variation in bacterial infections● Noninfectious causes increase procalcitonin
Kinetics
Figure 4: Kinetic Profiles of Various Biomarkers
Use in Bacterial Infections
● Respiratory Tract○ 2012 Cochrane meta-analysis
○ 14 randomized controlled trials
○ Similar protocols
○ Results
■ Strong reduction in initial antibiotic use for low-severity
infections
■ Earlier cessation of antibiotics with relative reduction in
duration
(Sager, Kutz, Mueller, & Schuetz, 2017)
Use in Bacterial Infections
● Blood Stream Infections○ No gold standard exists○ Procalcitonin demonstrated a high discriminatory ability○ May help discriminate contamination from BSI
Figure 5: Bloodstream infection
(Sager, Kutz, Mueller, & Schuetz, 2017)
Use in Bacterial Infections
● Sepsis, Severe Sepsis, and Septic Shock○ Reduced antibiotic treatment courses○ No increase in 28-day mortality○ No increase in ICU or hospital length of stay○ Helps predict severity of illness
(Sager, Kutz, Mueller, & Schuetz, 2017; Schuetz, Birkhahn, Sherwin, Jones, Singer, Kline, . . . Shapiro, 2017)
Use in Bacterial Infections
● Congestive Heart Failure○ May help differentiate heart failure exacerbation from infection○ More information is needed
Figure 6: Heart failure(Sager, Kutz, Mueller, & Schuetz, 2017)
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Use in Bacterial Infections
● Urinary Tract Infections○ Reductions in antibiotic use○ No negative effects
(Sager, Kutz, Mueller, & Schuetz, 2017)
Use in Bacterial Infections
● Febrile Neutropenia○ Accurate marker of infection ○ Predictor of severity○ Not suitable for determining treatment cessation
(Sager, Kutz, Mueller, & Schuetz, 2017)
Use in Bacterial Infections
● Meningitis○ Reduces antimicrobial consumption ○ Helps differentiate viral from bacterial meningitis○ Useful in prognostication
Figure 7: Meningitis(Sager, Kutz, Mueller, & Schuetz, 2017)Figure 8: Summary of evidence for PCT
Figure 9: Procalcitonin-based algorithm for antibiotics
Figure 10: Procalcitonin-based algorithm for antibiotics
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Figure 11: PCT algorithm for antibiotic therapy
Who cares?
Antibiotic Resistance
● One of the most urgent threats to the public’s health● 2 million people infected with antibiotic resistant bacteria● 23,000 people die from these infections
(CDC, 2013)
Figure 12: Antibiotic Resistance Threats
Economic Impact
● At least 30% of antibiotic courses prescribed in the outpatient setting unnecessary
● Antibiotics for children down, but almost 30% still unnecessary
● Antibiotics cause 1 out of every 5 ED visits for adverse drug events
● $55 billion in direct and indirect costs annually
(CDC, 2016)
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Economic Impact
● Approximately ⅓ of hospitalized patients and ⅔ of critically ill patients are on antimicrobial therapy
● Up to ½ of antibiotic prescriptions are inappropriate or not necessary
(Karanika, Paudel, Grigoras, Kalbasi, & Mylonakis, 2016)
Antibiotic Resistance
● Slow the emergence of resistant bacteria and prevent the spread of resistant infections
● Strengthen national One-Health surveillance efforts to combat resistance
● Advance development and use of rapid and innovative diagnostic tests for identification and characterization of resistant bacteria
Antibiotic Resistance● Accelerate basic and applied
research and development for new antibiotics, other therapeutics, and vaccines
● Improve international collaboration and capacities for antibiotic-resistance prevention, surveillance, control, and antibiotic research and development
Antibiotic Resistance
● Fiscal year 2017--Congress appropriated $163 million● Antibiotic Resistance Solutions Initiative
○ Detect, Respond, and Contain○ Prevent○ Innovate
(CDC, 2018)
(CDC, 2018)
What is Antibiotic Stewardship?
● Integrated strategy of improving antimicrobial use, including drug resistance and nosocomial infections
● Selecting the appropriate agent, dose, therapy duration and route of administration
(Karanika, Paudel, Grigoras, Kalbasi, & Mylonakis, 2016)
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GOALS
Cost
Con
tain
men
t
Ensure Patient Safety
Reduce Resistance
CDC Core Elements
● Antibiotic Stewardship in Acute Care: A Practical Playbook
● Hospital Antibiotic Stewardship Programs● Outpatient Antibiotic Stewardship● MITIGATE Antimicrobial Stewardship Toolkit● Antibiotic Stewardship Core Elements at Small and
Critical Access Hospitals
Core Elements of Hospital Antibiotic Stewardship
● Leadership Commitment● Accountability● Drug Expertise● Action● Tracking● Reporting● Education
Benefits of Antibiotic Stewardship Programs
● Improves clinical outcomes● Decreases costs● Helps reduce antibiotic resistance
Conclusion
● Use of serial procalcitonin measurements can help improve Antibiotic Stewardship programs○ Reduces antibiotic usage○ Reduces antibiotic duration
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Figure 13: Questions
ReferencesAntibiotic / Antimicrobial Resistance. (2018, January 31). Retrieved August 10, 2018, from https://www.cdc.gov/drugresistance/solutions-initiative/index.html
Antibiotic Resistance Investments. (n.d.). Retrieved August 10, 2018, from https://www.cdc.gov/arinvestments
Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C., Schuetz, A. N., Septimus, E. J., . . . Trivedi, K. K. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, 62(10), e51-77. doi:10.1093/cid/ciw118
Karanika, S., Paudel, S., Grigoras, C., Kalbasi, A., & Mylonakis, E. (2016). Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs. Antimicrobial Agents and Chemotherapy, 60(8), 4840-4852. doi:10.1128/AAC.00825-16
Sager, R., Kutz, A., Mueller, B., & Schuetz, P. (2017). Procalcitonin-guided diagnosis and antibiotic stewardship revisited. BMC Medicine, 15(1), 15. doi:10.1186/s12916-017-0795-7
Schuetz, P., Birkhahn, R., Sherwin, R., Jones, A. E., Singer, A., Kline, J. A., . . . Shapiro, N. I. (2017). Serial Procalcitonin Predicts Mortality in Severe Sepsis Patients: Results From the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) Study. Critical Care Medicine, 45(5), 781-789. doi:10.1097/CCM.0000000000002321
U.S.Cong. (2015). National action plan for combating antibiotic-resistant bacteria[Cong.]. Washington, D.C.: U.S. White House.
Vijayan, A. L., Vanimaya, Ravindran, S., Saikant, R., Lakshmi, S., Kartik, R., & G, M. (2017). Procalcitonin: a promising diagnostic marker for sepsis and antibiotic therapy. Journal of Intensive Care, 5, 51. doi:10.1186/s40560-017-0246-8
Contact Information
Patrick A. Laird, DNP, RN, ACNP-BC