Using procalcitonin to care for hospitalized patients Hospitalist Best Practice J Rush Pierce Jr, MD, MPH Division of Hospital Medicine July 22, 2015.

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Presentation transcript:

Using procalcitonin to care for hospitalized patients Hospitalist Best Practice J Rush Pierce Jr, MD, MPH Division of Hospital Medicine July 22, 2015

Roadmap for today Illustrative cases Procalcitonin: what it is and why it might work Evidence for usefulness of procalcitonin in settings of specific interest to hospitalists Availability and cost Use of Procalcitonin – possible clinical algorithms Discussion with specialists and experts 07/24/2014 Using procalcitonin to care for hospitalized patients 2

Disclosures Financial: none Biases: – Evidence should inform our thinking – Local variation is an interesting part of life – Medicine is fun 07/24/2014 Using procalcitonin to care for hospitalized patients 3

Case 1 64 y/o man with DM, HTN, HFpEF admitted with 1 wk of increased SOB, cough, gray sputum and chills. Exam: T = 37.5, JVD, rales at right base and trace edema. WBC = 13,000, BNP = 800. CXR shows “peribronchial cuffing & reticular opacities could represent developing pneumonia vs. interstitial edema, clinical correlation advised” 07/24/20144 Using procalcitonin to care for hospitalized patients

Clinical questions 1.Does this patient have a respiratory infection, CHF or both? 2.Should I order antibiotics on admission? 3.Should he go home on antibiotics? 07/24/20145 Using procalcitonin to care for hospitalized patients

Case 2 83 y/o woman with dementia at SNF recovering from hip fx, adm to MICU looking dry with BP = 80, acute delirium and AKI. WBC = 14,000, lactate = 4.5, 35 WBC’s in urine on admission and CXR with right lower lobe opacities c/w atelectasis vs possible aspiration. Put on Unasyn and vanc, volume resuscitated. Blood, urine cultures neg, CXR about same, now being transferred to floor. 07/24/20146 Using procalcitonin to care for hospitalized patients

Clinical questions 1.Did this patient have severe sepsis due to an infection, or delirium precipitated by volume depletion without infection? 2.Should I continue antibiotics now? 3.Should she go back to the SNF on antibiotics? 07/24/20147 Using procalcitonin to care for hospitalized patients

Procalcitonin: what it is and why it might work 07/24/2014 Using procalcitonin to care for hospitalized patients 8

Procalcitonin Calcitonin – a hormone seeking a job – Produced by parafollicular cells in thyroid – Opposes effect of PTH, inhibits osteoclasts, stimulates osteoblasts – No known pathologic state associated with deficiency Procalcitonin – precursor molecule processed by parafollicular cells to calcitonin – Undetectable in normal state 07/24/2014 Using procalcitonin to care for hospitalized patients 9

Calcitonin 07/24/2014 Using procalcitonin to care for hospitalized patients 10 Source: Muller B: Swiss Med Wkly 2001:131:595

Procalcitonin in sepsis Rises dramatically with bacterial infections, but very little with viral infections Rarely rises in sepsis due to non-infectious origin Peak levels correlates with prognosis Levels fall when bacterial infection treated Not affected by immune suppression Half-life 25 – 30 hours 07/24/2014 Using procalcitonin to care for hospitalized patients 11

Procalcitonin and sepsis prognosis 07/24/2014 Using procalcitonin to care for hospitalized patients 12 Source: Jensen J: Crit Care Med 2006;34:2596

Why procalcitonin might be useful Diagnosis of infection is often difficult – Clinical tools have significant limitations – Specific etiology often elusive (sepsis <50%, CAP <30%) Antimicrobial use has its downsides – Key driver to antibiotic resistance – Can be associated with adverse reactions – Major risk factor for C difficele – Often costly 07/24/2014 Using procalcitonin to care for hospitalized patients 13

Evidence for usefulness of procalcitonin in settings of specific interest to hospitalists 07/24/2014 Using procalcitonin to care for hospitalized patients 14

ProHOSP Trial Prospective randomized controlled trial; 6 ED’s in Switzerland, pts presenting with possible LRTI (CAP, bronchitis, exacerbation of COPD) Initiation and continuation of antibiotic based on clinician judgment vs PCT algorithm IN PCT algorithm arm, clinician could overrule for specific indication 07/24/2014 Using procalcitonin to care for hospitalized patients 15 Source: Schuetz P: JAMA 2009;302:1059

07/24/2014 Using procalcitonin to care for hospitalized patients 16 Source: Schuetz P: JAMA 2009;302:1059

07/24/2014 Using procalcitonin to care for hospitalized patients 17 Source: Schuetz P: JAMA 2009;302:1059

07/24/2014 Using procalcitonin to care for hospitalized patients 18 Source: Schuetz P: JAMA 2009;302:1059

ProHOSP Trial - conclusions In patients with LRTIs, a strategy of PCT guidance compared with standard guidelines resulted in – similar rates of adverse outcomes, as well as – lower rates of antibiotic exposure – lower rates of antibiotic-associated adverse effects. 07/24/2014 Using procalcitonin to care for hospitalized patients 19 Source: Schuetz P: JAMA 2009;302:1059

PRORATA Trial Prospective randomized controlled trial; 5 ICU’s in France, pts adm to ICU with suspected sepsis Initiation and continuation of antibiotic based on clinician judgment vs PCT algorithm IN PCT algorithm arm, clinician could overrule for specific indication 07/24/2014 Using procalcitonin to care for hospitalized patients 20 Source: Bouadma L: Lancet 2010;375:463

07/24/2014 Using procalcitonin to care for hospitalized patients 21 Source: Bouadma L: Lancet 2010;375:463

07/24/2014 Using procalcitonin to care for hospitalized patients 22

07/24/2014 Using procalcitonin to care for hospitalized patients 23 Source: Bouadma L: Lancet 2010;375:463

PRORATA Trial - Conclusions A procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical patients in intensive care units could reduce antibiotic exposure and selective pressure with no apparent adverse outcomes. 07/24/2014 Using procalcitonin to care for hospitalized patients 24 Source: Bouadma L: Lancet 2010;375:463

BACH Trial International multicenter cohort study, patients presenting to ED with dyspnea and acute heart failure (AHF) was diagnostic consideration Signs, sxs, lab, markers including PCT 30, 60, 90 day mortality 07/24/2014 Using procalcitonin to care for hospitalized patients 25 Source: Maisal A: European J Heart Failure 2012;14, 278

07/24/2014 Using procalcitonin to care for hospitalized patients 26 Source: Maisal A: European J Heart Failure 2012;14, 278

BACH Trial - Conclusions Procalcitonin may aid in the diagnosis of pneumonia, particularly in cases with high diagnostic uncertainty. PCT may aid in the decision to administer antibiotic therapy to patients presenting with AHF in which clinical uncertainty exists regarding a superimposed bacterial infection. 07/24/2014 Using procalcitonin to care for hospitalized patients 27 Source: Maisal A: European J Heart Failure 2012;14, 278

Meta-analysis of PCT use 07/24/2014 Using procalcitonin to care for hospitalized patients 28 Source: Schuetz P: Arch Intern Med 2011;171:1322

07/24/2014 Using procalcitonin to care for hospitalized patients 29 Source: Schuetz P: Arch Intern Med 2011;171:1322

Case 1 64 y/o man with DM, HTN, HFpEF admitted with 1 wk of increased SOB, cough, gray sputum and chills. Exam: T = 37.5, JVD, rales at right base and trace edema. WBC = 13,000, BNP = 800. CXR shows “peribronchial cuffing & reticular opacities could represent developing pneumonia vs. interstitial edema, clinical correlation advised” 07/24/ Using procalcitonin to care for hospitalized patients

Clinical questions 1.Does this patient have a respiratory infection, CHF or both? 2.Should I order antibiotics on admission? 3.Should he go home on antibiotics? 07/24/ Using procalcitonin to care for hospitalized patients

Case 2 83 y/o woman with dementia at SNF recovering from hip fx, adm to MICU looking dry with BP = 80, acute delirium and AKI. WBC = 14,000, lactate = 4.5, 35 WBC’s in urine on admission and CXR with right lower lobe opacities c/w atelectasis vs possible aspiration. Put on Unasyn and vanc, volume resuscitated. Blood, urine cultures neg, CXR about same, now being transferred to floor. 07/24/ Using procalcitonin to care for hospitalized patients

Clinical questions 1.Did this patient have severe sepsis due to an infection, or delirium precipitated by volume depletion without infection? 2.Should I continue antibiotics now? 3.Should she go back to the SNF on antibiotics? 07/24/ Using procalcitonin to care for hospitalized patients

Availability and cost of procalcitonin at UNMH Currently sent out to ARUP Reference Lab – FedEx afternoons Mon – Fri to ARUP, run next day, reported within 24 hrs – 3 to 5 day turnaround Charge = $ /24/2014 Using procalcitonin to care for hospitalized patients 34

Use of Procalcitonin – possible clinical algorithms 07/24/2014 Using procalcitonin to care for hospitalized patients 35

07/24/2014 Using procalcitonin to care for hospitalized patients 36 Source: Schuetz P: BMC Medicine 2011;9:107

07/24/2014 Using procalcitonin to care for hospitalized patients 37 Source: Schuetz P: BMC Medicine 2011;9:107

Discussion with specialists and experts Should we advocate for POC PCT testing? Should we use PCT to guide initiation and continuation of antibiotic therapy for: – LRTI – Pts coming out of ICU on antibiotics Should we teach use of PCT to learners? 07/24/2014 Using procalcitonin to care for hospitalized patients 38