ACP HospitalistProcalcitonin Do’s and Don’ts

There are best practices for making the most of this blood test, even though the optimum way to use procalcitonin is still up for debate.

Procalcitonin, a hot topic in hospital medicine since 2017, has shown promise in guiding antibiotic decision-making for specific patient populations. Amid varying opinions on its optimal use, physicians and researchers have identified best practices to extract the maximum value from this blood test.

Key Points:

• Procalcitonin use has increased dramatically since 2017, particularly amidst the COVID-19 pandemic, with about 20% of hospitalized patients receiving procalcitonin testing in Michigan.
• A study led by Dr. Valerie Vaughn demonstrated procalcitonin’s high negative predictive value (98.3%) for bacterial co-infection in COVID-19 patients, assisting in decisions around antibiotic use.
• FDA-approved uses of procalcitonin testing include determining whether antibiotics should be started or stopped in patients with lower respiratory tract infections or sepsis.
• The utilization of procalcitonin has been linked with a 25% reduction in antibiotic use and an overall mortality benefit in more than 20 randomized controlled trials.
• However, effective implementation is challenged by clinicians’ emotional decision-making around antibiotics, often disregarding procalcitonin results when they conflict with pre-established antibiotic plans.

Additional Points:

• Dr. Vaughn suggests procalcitonin is best used when diagnostic tests do not align or in cases of diagnostic uncertainty, like a patient with COVID-19 presenting with high fevers.
• Procalcitonin’s effectiveness is limited in diagnosing pneumonia, with a sensitivity and specificity for bacterial infection of 55% and 76%, respectively, according to a meta-analysis of 12 studies in 2,408 patients.
• The optimal use of procalcitonin occurs when a patient is admitted with a likely viral diagnosis, such as confirmed influenza, but a secondary bacterial infection is suspected.
• Implementation of procalcitonin testing within a broader antibiotic stewardship program, especially one extending into the post-discharge period, may yield the greatest effectiveness.

Conclusion:

• Although the use of procalcitonin is growing, its optimal application remains debated. It shows promise in guiding antibiotic usage, reducing unnecessary prescriptions, and assisting with diagnostic uncertainty. However, the challenges lie in effectively changing clinician behavior and understanding its limitations in diagnosing certain conditions.

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