A Service Evaluation of Procalcitonin after PRORATA Daniel Cottle DICM John Butler, Tony Dunne, Sanchia Pickering Manchester Royal Infirmary 2011

Antimicrobial resistance in ICU CPC MRSA

Antimicrobial resistance in ICU Major factor affecting patient outcome and resources. Insufficient infection control measures. Selective antibiotic pressure. Reducing antibiotic use may contain the emergence of multi-drug resistance bacteria in ITUs. Stop inappropriate prescribing. Shorten duration of treatment of antibiotics.

Procalcitonin Normally produced by the C-cells of the thyroid Normally undetectable Unknown role in sepsis Multiple sources in sepsis Analgesic

Procalcitonin – in relevant bacterial infection produced and released into circulation from the whole body Calcitonin in healthy personsPCT in bacterial infection Calcitonin PCT Müller B. et al., JCEM

Procalcitonin- Kinetics Fast increase of PCT after bacterial challenge Fast increase (after 3-4 hours), high dynamic range Wide concentration range < 0.05 ng/ml ng/ml Short half-life time (~ 24 h) independent of renal function Easy to measure in serum and plasma - stable in vivo and in vitro Brunkhorst FM et alIntens Care Med 1998; 24:

PRORATA Lancet 2010 Multicentre, randomised, controlled trial. 311 procalcitonin, 319 control. Days without antibiotics: – 14.3 days PCT : 11.6 control. The mean duration of the first episode of antibiotics was reduced from 9.9 days to 6.1 days, AR 3.8 days; 95% CI , p< No increase in mortality

Figure 3 Source: The Lancet 2010; 375: (DOI: /S (09) )The Lancet 2010; 375: Terms and Conditions

Methods Baseline data collection Protocol Introduction of protocol Promote protocol Reinforce protocol Data collection Analysis Mean (standard deviation) Student’s t-test

Exclusions Post bone marrow transplant Pregnancy TB, PCJ, toxoplasmosis Neutropenia Expected to die

Example Patient 38 DateClinical eventsAntibioticsCRPWBCPCTMicrobiology culture Temp Highest or Lowest LactateVentilated Y/N Antibiotic Changes 8/12/2011 coamoxyclav, clari y 8/13/2011 coamoxyclav, clari y 8/14/2011 coamoxyclav, clari y 8/15/2011 coamoxyclav, clari y 8/16/2011 coamoxyclav, clari yy 8/17/2011?chest sepsisTazocin yn 8/18/2011 Tazocin >80% Reduction yn

Results 60 antibiotic episodes 8 to the ward 4 died 6 exclusions 42 analysed

29 stopped early 8 no difference 1 escalated because 4 escalated despite

Chest sepsis Mean course length 5.5 days PRORATA: CAP 5.5 days, VAP 7.7 days 8 had a starting PCT <0.5 3 could have stopped earlier

Abdo sepsis Mean course length 7.9 days PRORATA: 8.1 days 4 escalated despite PCT 1 could have stopped earlier

Conclusions PCT reduced antibiotic use on our unit Definite end-point More structured approach Could this be reduced further? PCT <0.5 as a rule out?

QUESTIONS?