Safe procalcitonin practice reduces antibiotic overuse

brahms pct procalcitonin antibiotic guidanceAntibiotics can save lives, but their increasingly unwarranted use in healthcare is causing the growth of antimicrobial resistance.

Thermo Fisher Scientific’s B·R·A·H·M·S Procalcitonin can help to reduce unnecessary antibiotic prescriptions.

In many cases the prescription of antibiotics is rather unnecessary. Especially in lower respiratory tract infections (LRTI) the infection has predominantly a viral origin. Still 75% of the patients are treated with antibiotics Ref-1. In critically ill patients with sepsis, severe sepsis, or severe bacterial infections like pneumonia the duration of the antibiotic therapy is often longer than necessary and could be stopped earlier without any adverse impact on the patient Ref-2 . This antibiotic overuse contributes to increasing antimicrobial resistance, increased risk of drug-related adverse events and higher medical costs.

A well described approach for determining the necessary and optimal duration of antibiotic therapy is the use of the biomarker PCT, which becomes upregulated during bacterial infections and mirrors the severity of infections.

B·R·A·H·M·S PCT-guided antibiotic therapy has been investigated in various interventional studies, which suggest that the duration of antibiotic therapy can be shortened and the overall prescription of antibiotics significantly reduced, without any adverse patient outcome. PCT guidance for antibiotic de-escalation is also recommended in the ‘Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: Update 2012’.

Use of B·R·A·H·M·S PCT in the Emergency Department / out-patient settings

Due to the high specificity for bacterial infection, PCT measurement can be helpful in patients coming to Emergency Department (ED) with respiratory tract infection. However, the application of the established clinical algorithms should be adapted to patient acuity (risk level) and clinical setting (see graphic). E.g., a PCT value < 0.25μg/L has a high negative predictive value to exclude a serious bacterial infection. In low-risk patients presenting to the ED, this cut-off can be used to limit start of antibiotics to those patients that potentially would benefit from the treatment Ref-3.

Use of B·R·A·H·M·S PCT in ICU

For high acuity patients, a PCT cut-off of 0.5μg/L is recommended. PCT levels below this cut-off make severe bacterial infections and sepsis unlikely and other diagnoses explaining the patients’ medical condition should be considered. Furthermore when critically ill patients are monitored, decreasing PCT levels can guide to reduce antibiotic exposure safely in order to discontinue antibiotics earlier Ref-3.

pct-algorithm-guidance-antibiotic-therapyFigure: Cut-off levels of clinical algorithms adapted to patients' acuity (adapted from Ref-1)
a Consider use of antibiotics if patients are clinically unstable, have strong evidence of pneumonia, are at high risk (i.e., COPD GOLD III-IV), or need hospitalization.
b Bacterial infection is likely.
c Low risk of significant bacterial infection; consider other diagnoses.
d Sepsis is likely in patients with PCT > 0.5 μg/L and clinical suspicion of sepsis.
e Low risk of sepsis; other non-infectious diagnoses are more likely and should be considered.
f Consider continuation of antibiotics if patients are clinically unstable.


Impact of B·R·A·H·M·S PCT-guided antibiotic algorithms in LRTI and ICU

PCT-guided algorithms allow significant reduction of antibiotic treatment duration compared to routine practice. Patients with LRTI showed a reduction of 35% of antibiotic exposure Ref-1. Using PCT guided algorithm for critically ill patients in ICU could safely reduce antibiotic exposure by 23% Ref-2. Shorter antibiotic therapy is associated with cost savings, particularly when broad-spectrum antibiotics are used.

An even more impressive impact on treatment-related costs comes from reduction of ICU length of stay as demonstrated in several studies in ICU patients treated for sepsis. The studies show that the patients in the PCT group were discharged from ICU to normal ward 2 days earlier than standard group patients Ref-4,5. This further enhanced the saving effect of antibiotic discontinuation, based on a PCT-guided clinical algorithm, with an estimated saving per patient of about Euro 3500, representing savings of 9.2%, respectively Ref-6.

Shorter antibiotic treatment duration also contributes to prevent development of resistance in nosocomial microorganisms.

Established PCT clinical cut-offs and decision algorithms have been developed using B·R·A·H·M·S PCT assays. For safe clinical decision making, using a B·R·A·H·M·S PCT assay ensures a safe application of these cut-offs and algorithms.


Ref-1: Schuetz et al., JAMA 2009, 302: 1059-66

Ref-2: Bouadma L et al. Lancet 2010, 375 (9713): 463-474

Ref-3: Schuetz P et al. Expert Rev Anti Infect Ther 2010, 8 (5): 575-87

Ref-4: Hochreiter M et al. Crit Care 2009, 13 (3): R83

Ref-5: Nobre S et al. Am J Respir Crit Care Med 2008, 177 (5): 498-505

Ref-6: Kip M et al. Journal of Medical Economics 2015, 1–10

thermo scientific applied biosystems invitrogen fisher scientific unity lab service