PROCALCITONIN: ADVANCING DECISION
MAKING IN SEPSIS
Sean-Xavier Neath, M.D., Ph.D.
Assistant Clinical Professor of Medicine
Department of Emergency Medicine
University of California, San Diego
OBJECTIVES
•
•
•
•
Explore the scope of sepsis, its costs and effects on the healthcare
system
Identify the difficulties associated with the rapid diagnosis of
sepsis with a focus on the differentiation of bacterial from nonbacterial causes of SIRS
Utilize the performance characteristics of the biomarker
procalcitonin (PCT) as a marker of sepsis or significant bacterial
infection
Interpret PCT levels and understand current PCT utilization in the
hospital
2
DISCLOSURES
1) Consultant relationships with biomedical companies working on
biomarkers in acute disease states
Thermo Fisher Scientific
BRAHMS
2) Employed by the University of California, San Diego Medical Center as an
Assistant Professor of Clinical Medicine, Department of Emergency
Medicine
3
WHAT IS SEPSIS?
•
Whole Body Inflammatory State plus Infection
4
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)
•
•
•
•
•
Systemic inflammatory response to a variety of severe clinical
insults. Manifested by two or more of the following:
Temperature >38ºC or <36ºC
Heart rate >90 beats/min
Respiratory rate >20 breaths/min or PaCO2 <32 mm Hg
WBC >12,000/mm3, <4000/mm3, or >10% immature (band)
forms
ACCP/SCCM Consensus Statement. Chest.
1992;101:1644-1655.
5
SEPSIS: ACCP/SCCM DEFINITIONS
•
Sepsis
• Systemic response to infection – i.e., confirmed or suspected
infection plus 2 SIRS criteria
•
Severe Sepsis
• Sepsis associated with organ dysfunction, hypoperfusion, or
hypotension
•
Septic Shock
• Severe Sepsis that cannot be resuscitated or stabilized with IV fluids
alone
ACCP/SCCM Consensus Statement. Chest. 1992;101:1644.
6
Slide
Parasite
Virus
Infection
Fungus
Severe
Sepsis
shock
SIRS
Sepsis
Severe
SIRS Trauma
Bacteria
BSI
Adapted from SCCM ACCP Consensus Guidelines
Burns
POPULATION ADJUSTED INCIDENCE OF SEPSIS (USA)
Martin GS et al. NEJM 2003;348:1346
8
CASES OF SEPSIS BY PATHOGEN (USA)
Martin GS et al. NEJM 2003;348:1346
9
INFECTION SOURCE IN SEVERE SEPSIS
10.8%
6.0%
8.0%
44.0%
2.2%
6.6%
8.6%
9.1%
Respiratory
Bacteremia
GU
Abdomen
Soft tissue
Device
CNS
Endocarditis
Other
17.3%
Angus DC et al. Crit Care Med. 2001; 29:1303
10
DETERMINANTS OF MORTALITY
•
•
•
Source control is most vital factor
Resuscitation/re-establish perfusion in 6 hrs
Appropriate antibiotic therapy within 1 hr of hypotension
11
TREATMENT OF SEPTIC SHOCK
•
•
•
•
•
Source Control When Possible
Based on Early Goal Directed Therapy
Broad, high dose, rapid administration of antibiotics
Consider Activated Protein C
Minimal role for steroids
Surviving Sepsis Campaign: International guidelines for management of severe
sepsis and septic shock, 2008. Critical Care Med
12
DIFFICULTIES IN DIAGNOSIS AND TREATING SEPSIS IN THE
EMERGENCY DEPARTMENT
• Differentiation between sepsis and non-infectious causes of SIRS is
complicated
• The large number of patients presenting to the ER at the same
time can limit the ability to obtain comprehensive histories and
physical examinations
13
DIFFICULTIES IN DIAGNOSIS AND TREATING SEPSIS IN THE
EMERGENCY DEPARTMENT
• Scoring systems and commonly available diagnostic tools provide
limited value in determining which patients will have a poor
outcome
• Initial vital signs can be incomplete, an accurate core temperature
can be lacking
• These limitations often result in the delayed diagnosis of sepsis
which in turn delays treatment, increases hospital length-of-stay,
increases costs and leads to increased preventable mortality
14
DURATION OF HYPOTENSION BEFORE INITIATION OF EFFECTIVE ANTIMICROBIAL
THERAPY IS THE CRITICAL DETERMINANT OF SURVIVAL IN HUMAN SEPTIC SHOCK
Kumar A. et al., Crit Care Med 2006, 34:1286
15
FAILURE TO INTERVENE QUICKLY CAN BE FATAL
Sebat CCM 2007; 35: 2568
16
Key Areas of Sepsis Management
•
•
•
•
•
•
•
•
•
Initial Resuscitation
Diagnosis
Antibiotic therapy
Source Control
Fluid therapy
Vasopressors
Inotropic Therapy
Steroids
Recombinant Human
Activated Protein C (rhAPC)
[drotrecogin alfa (activated)]
 Blood Product Administration
 Mechanical Ventilation
 Sedation, Analgesia, and Neuromuscular Blockade
in Sepsis
 Glucose Control
 Renal Replacement
 Bicarbonate Therapy
 Deep Vein Thrombosis Prophylaxis
 Stress Ulcer Prophylaxis
 Limitation of Support
Dellinger, et. al. Crit Care Med 2004, 32: 858-873.
17
ROLE OF PROCALCITONIN IN INITIAL SEPSIS
MANAGEMENT
WHY PROCALCITONIN?
Integrated use of PCT with other
clinical and laboratory information
permits:
• Increased accuracy of clinical diagnosis of
relevant bacterial infection / sepsis
• Improved clinical decision making and
patient management
19
PROCALCITONIN – A BIOMARKER FOR THE ASSESSMENT OF CRITICALLY
ILL PATIENTS AT RISK FOR SEVERE BACTERIAL INFECTION AND SEPSIS
•
•
•
Simple blood test specific for bacterial infection
During severe bacterial infections and sepsis, blood levels rise rapidly (up to x100K) – no
elevation from viral infections
Is the Standard of Care for much of Europe in the management of infection and sepsis
Morgenthaler N. et al., Clin Lab 2002, 48: 263-270
20
PROCALCITONIN – NORMALLY AN INTERMEDIATE PRODUCT IN THE
SYNTHESIS OF CALCITONIN
Thyroid
After P. Linscheid, Endocrinology 2003
N-Pro
Calcitonin
Katacalcin
N
C
1
57 60
91 96
116
LOW PCT values in the blood of healthy persons: 46.7 pg/ml (97.5 percentile); median = 12.7 pg/ml*
Morgenthaler N. et al., Clin Lab 2002, 48: 263-270
21
PROCALCITONIN – PRESENCE OF BACTERIAL INFECTION STIMULATES
PCT PRODUCTION
Alternative synthesis of PCT
• Bacterial toxins (gram+/-) and cytokines stimulate production of PCT in all
parenchymal tissues
• PCT is immediately released into bloodstream
• This process can be blocked during viral infections
Adapted from Christ-Crain et al. 2005
22
HIGHLY SPECIFIC INDUCTION AND RELEASE OF PCT DUE TO BACTERIAL
INFECTION
Calcitonin:
Sources of
production
in healthy
people
Healthy Sepsis
PCT:
Sources of
Production
in Septic
Patients
• In bacterial infection, PCT is produced and released into
circulation from the entire body
Müller B. et al., JCEM 2001
23
PCT LEVEL INCREASE = INCREASED SIGNIFICANCE OF BACTERIAL
INFECTION
2 ng/ml
0.5 ng/ml
0.05 ng/ml
Healthy
Individuals
•
•
•
Local
Infections
Systemic
Infections
(Sepsis)
Severe
Sepsis
Septic
Shock
In critically ill patients, PCT levels elevate in correlation to the severity of bacterial
infection
In healthy people, PCT concentration are found below 0.05ng/ml
Concentrations exceeding 0.5ng/ml can be interpreted as abnormal
24
HIGHLY SPECIFIC INDUCTION AND RELEASE OF PCT DUE TO BACTERIAL
INFECTION
• IFN- released in viral infection, blocks the activation of
PCT production, therefore in viral infection PCT levels
remain normally low
Adapted from Christ-Crain et al. 2005
25
BENEFITS AND LIMITATIONS OF OTHER SEPSIS DIAGNOSTIC TOOLS
Microbiology (Blood Culture)
Standard of care, time to result,
?Sens., ? Spec.
Imaging (X-Ray, Hr-CT)
Availability, costs, variability of
source detection
Molecular Biological Testing
Availability, costs, time to results
Biopsy
Invasive, relatively expensive
Biomarker Testing (PCT)
Easy to measure, not invasive,
relatively inexpensive
C-Reactive Protein (CRP)
Slow kinetics , high impact of
inflammation (specificity), suppressed
by corticosteroids, relatively
inexpensive
26
DIAGNOSTIC ACCURACY OF PCT COMPARED TO OTHER BIOMARKERS
USED IN SEPSIS
Sensitivity: 89%
Specificity: 94%
NPV: 90% / PPV: 94%
•
•
PCT levels accurately differentiate sepsis from noninfectious inflammation*
PCT has been demonstrated to be the best marker for differentiating patients with sepsis from
those with systemic inflammatory reaction not related to infectious cause
Simon L. et al. Clin Infect Dis. 2004; 39:206-217.
27
ADDING PCT RESULTS TO CLINICAL ASSESSMENT IMPROVES THE
ACCURACY OF THE EARLY CLINICAL DIAGNOSIS OF SEPSIS
AUC with PCT: 0.94
AUC without PCT: 0.74
•
When PCT is used as a reference, the sensitivity and specificity of sepsis
diagnosis can be significantly increased compared with conventional clinical
parameters.
Harbarth S et.al. AM J Resp Crit Care Med. 2001; 164:396-402
28
PCT LEVELS INCREASE
•
•
•
ACCORDING TO SEVERITY OF SEPSIS
PCT can aid in the diagnosis and severity stratification in patients suspected of sepsis,
severe sepsis, and septic shock.
In multiple studies, PCT has demonstrated a high sensitivity and specificity for the
differentiation of sepsis from SIRS (Systemic Inflammatory Response Syndrome)
PCT levels can be useful for the management of patients after surgery or transplant and in
peritonitis
Harbarth S et al. Am J Respir Crit Care Med 2001, 164: 396-402 ; Meisner M et al., Critical Care 1999, 3(1): 45-50 ; Krüger S. et al., Eur
Respir J 2008; 31: 349–355
29
ADDING PCT RESULTS TO CLINICAL ASSESSMENT IMPROVES THE
ACCURACY OF THE EARLY CLINICAL DIAGNOSIS OF INFECTION POST
ORGAN TRANSPLANT
PCT plasma concentrations in 16
patients without postoperative
complications after LiverTransplantation, Tx: day of
transplantation.
PCT plasma concentrations in
infection and rejection (n = 11),
day 0: day of diagnosis
• PCT used in early detection of infection after liver transplantation
– differentiation from rejection
Kuse ER et al., Crit Care Med 2000; 28: 555-559
30
PCT KINETICS PROVIDE IMPORTANT INFORMATION ON PROGNOSIS OF
SEPSIS PATIENTS
•
•
Clinical symptoms alone are often insufficient for early and accurate diagnosis
PCT levels, can be observed within 3-6 hours after an infectious challenge with a
peak - up to 1000 ng/ml - after 6-12 hrs. Half-life: ~24hrs
•
Specific to bacterial origin of infection and reflects the severity of the infection
Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892
31
INTERPRETING PROCALCITONIN VALUES
32
PCT RELEASE IN THE ABSENCE OF INFECTION
•
Newborn < 48hr - increased PCT values (physiological peak)
• On 3rd day after birth, normal adult reference ranges apply
•
Primary inflammation syndrome following trauma: multiple trauma,
extensive burns, major surgery (cardiac, transplant, abdominal)
• Rapid decrease (half-life 24hr) in the absence of bacterial infection
•
Medullary C-cell cancers of the thyroid, pulmonary small-cell carcinoma
and bronchial carcinoma
•
Prolonged circulatory failure (e.g.. cardiogenic shock, hemorrhagic
shock, thermal shock)
•
Treatments that can cause a cytokine storm e.g. OKT3, anti-lymphocyte
globulins, etc.
33
ADDING PCT RESULTS TO CLINICAL ASSESSMENT IMPROVES THE
ACCURACY OF THE EARLY CLINICAL DIAGNOSIS OF SEPSIS IN NEONATES
UNINFECTED
PCT
(ng/ml)
INFECTED
PCT
(ng/ml)
Time (hours)
Time (hours)
•
In early onset neonatal sepsis PCT provides a clear differentiation of infected from
uninfected neonates in the first 2 days of life
•
In neonates the PCT values are physiologically and in relation to their age increased.
•
A peak is reached at 24 h with Median at 2 ng/ml and 95%-Percentile at 20 ng/ml.
•
After 3 days the normal values for children and adults apply.
C Chiesa et al. CID 1997
34
CONDITIONS OF BACTERIAL INFECTION WHERE PCT MAY BE LOW IN
THE PRESENCE OF BACTERIAL INFECTION
Low PCT levels in the presence of bacterial
infection may occur:
•
•
•
Early course of infection: Re-measure in 6-12hrs
Subacute Endocarditis
Localized infections
35
INTERPRETATION OF PCT LEVELS
• PCT values must always be interpreted within the clinical context
of each individual patient
• Serial measurement is preferred to assess the situation in realtime
• Always pay attention to conditions that may influence the PCT
level
• Always consider the dynamics of the disease process (which
affect onset of PCT production)
36
PCT KINETICS AFTER AN INFECTIOUS CHALLENGE
Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892
•
•
•
•
Rapid kinetics: detectable 3 hours after infection has begun, with a peak
after 6-12 hrs.
Peak values up to 1000 ng/ml
Half-life: ~ to 24 hrs
Non or minor dependence on renal function
Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892
37
PCT REFLECTS THE RESPONSE OF THE ORGANISM TO THE BACTERIAL
CHALLENGE
• Elevated / rising PCT levels
• Systemic response to the infection - indicates that
infection is developing or is outside the control of the
immune system
• Risk for further progression
• Low PCT levels despite clinical signs and symptoms
• Self-limiting bacterial infection
• Non-infectious cause
• Early phase of infection
38
PROCALCITONIN UTILIZATION TO IMPROVE PATIENT CARE IN THE
HOSPITAL
39
NO PCT INCREASE IN BACTERIAL CONTAMINATION, ONLY
IN REAL BACTERIAL INFECTION
• In addition to clinical and microbiological
parameters, PCT may help discriminate
blood stream infections from blood
culture contamination due to coagulasenegative staphylococci
• At a cut-off of 0.1ng/ml sensitivities and
specificities were
• Day –1 of BC:
• Day 0 of BC:
86%
100%
and
and
60%
86%
• CRP could discriminate only on day +1,
but not as clear-cut as PCT
Schuetz P. et al., Infection 2007;35 (5): 352-5
40
PCT LEVELS PREDICT BACTEREMIA IN PATIENTS WITH COMMUNITY
ACQUIRE PNEUMONIA (CAP)
• Current guidelines recommend blood culture sampling
from hospitalized patients with suspected CAP. Is there a
way to reduce the patient harm, costs and errors
associated with these recommendations?
• Prospective cohort study with derivation and validation set
including 925 patients with CAP who underwent blood
culture sampling on hospital admission.
Muller et al. CHEST July 2010
41
PCT PREDICTS BACTEREMIA IN PATIENTS WITH CAP:
PATIENT FLOW IN DERIVATION AND VALIDATION COHORTS
Muller et al. CHEST July 2010
42
PCT CUTOFF OF 0.1 ENABLES REDUCTION OF BLOOD CULTURES BY
12.6% AND IDENTIFIES 99% OF POSITIVE BLOOD CULTURES
Muller et al. CHEST July 2010
43
PCT LEVELS PREDICT BACTEREMIA IN PATIENTS WITH COMMUNITY
ACQUIRE PNEUMONIA
• PCT levels accurately predicted blood culture positivity in
patients with CAP.
• PCT measurement demonstrated the potential to reduce the
number of blood cultures drawn in the ED to better
implement resources
• The use of PCT in targeting rational blood culture utilization
allows for more directing allocation of limited health-care
resources.
Muller et al. CHEST July 2010
44
PCT RESULTS PROVIDE IMPORTANT INFORMATION ON PROGNOSIS OF
CAP PATIENTS IN EMERGENCY ROOM
Mortality by PCT level
12%
10%
PCT
≥ 0.1
Mortality, %
8%
6%
4%
PCT < 0.1
2%
0%
0
5
10
15
20
25
30
Day
•
•
PCT can be used for Risk stratification of patients with CAP
Low PCT levels identify patients presenting in the ED with Pneumonia that have a low
risk for mortality (N=1,651).
Huang, et.al., Annals of Emergency Medicine, Vol 51, March 2008
46
SERIAL MEASUREMENT OF PCT PROVIDES A CLEARER PICTURE OF THE
PATIENT’S RESPONSE TO ANTIBIOTIC TREATMENT.
•
•
•
Decreasing PCT levels in patients with sepsis indicate effective treatment of the
underlying infection
Persistently elevated PCT levels indicate a possible treatment failure
When integrated into the management of septic patients, PCT can help clinicians to
manage septic patients more efficiently
Stueber, F. University of Bonn, Lecture at ISICEM, Brussels 2001
47
PCT GUIDANCE IN ANTIBIOTIC USAGE EFFECTS ON LENGTH OF STAY
•
Effect of PCT-guided management in patients with sepsis on ICU length of stay
Nobre V. et alAM Resp Crit Care Med 2008: 177:498-505
48
PCT GUIDANCE ON EFFECT ON LENGTH OF ICU STAY
•
Effect of PCT-guided management in patients with sepsis on ICU length of stay
Nobre V. et alAM Resp Crit Care Med 2008: 177:498-505
49
PCT GUIDANCE IN ANTIBIOTIC USAGE HAS BEEN SHOWN TO
SIGNIFICANTLY SHORTEN THE TIME PATIENTS NEED TO BE ON
ANTIBIOTICS
KEY TAKEAWAY:
Tailoring of AB treatment using PCT to the individual patient
needs safely led to a reduction of average treatment duration
from 12 to 5 days with same outcome
Nobre V. et al AM Resp Crit Care Med 2008: 177:498-505
50
EFFECT OF PCT TESTING ON ANTIBIOTIC USE – A
MULTICENTER, RANDOMIZED CONTROL TRIAL
The ProHOSP Trial
• Lower respiratory tract infections (LRTI)
• Most frequent indication for antibiotic prescriptions
in the Northwestern hemisphere
• 75% of patients are treated with antibiotics
• Predominantly viral origin of infection
• Procalcitonin (PCT) algorithm
• Reduced antibiotic use in patients with LRTIs
Schuetz P et al. J Am Med Assoc. 2009;302:1059-66.
51
51
STUDY DESIGN
• Multicenter, noninferiority, randomized controlled trial
• Patients
• Randomized to administration of antibiotics based on PCT algorithm
• Cutoff ranges for initiating or stopping antibiotics (PCT group) or
standard guidelines (control)
• Serum PCT was measured locally
• Main Outcome Measures
• Composite adverse outcomes of death, intensive care unit
admission, disease-specific complications, or recurrent infection
within 30 days
• Antibiotic exposure and adverse effects from antibiotics
Schuetz P et al. J Am Med Assoc. 2009;302:1059-66.
52
52
RATES OF COMBINED ADVERSE OUTCOMES
AND MORTALITY BY RANDOMIZATION GROUP
No. (%) of Patients
Group
All patients (intention-to-treat)
PCT
Group
Control
Group
Risk Difference, %
(95% CI)
(n = 671)
(n = 688)
103 (15.4)
130 (18.9)
−3.5 (−7.6 to 0.4)
Death
34 (5.1)
33 (4.8)
0.3 (−2.1 to 2.5)
ICU admission
43 (6.4)
60 (8.7)
−2.3 (−5.2 to 0.4)
Recurrence/rehospitalization
25 (3.7)
45 (6.5)
−2.8 (−5.1 to −0.4)
Per-protocol population
(n = 633)
(n = 650)
Overall adverse outcome
95 (15.0)
123 (18.9)
−3.9 (−8.2 to 0.03)
Death
29 (4.6)
31 (4.8)
−0.2 (−2.6 to 2.0)
Community-acquired pneumonia
(n = 460)
(n = 465)
Overall adverse outcome
74 (16.1)
94 (20.2)
−4.1 (−9.1 to 0.9)
Death
24 (5.2)
26 (5.6)
−0.4 (−3.3 to 2.6)
Overall adverse outcome
53
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
Antibiotic Exposure in Patients
Receiving Antibiotic Therapy
PCT
Control
All Patients
(n = 1359)
Community-acquired Pneumonia
(n = 925)
Patients Receiving
Antibiotic Therapy, %
100
80
60
40
20
0
0
1
2
5
7
9 11 >13
Time After Study Inclusion, d
No. of Patients
PCT
506 484 410 306 207 138 72 46
Control 603 589 562 516 420 324 157 100
0
1
2
5
7
9 11 >13
Time After Study Inclusion, d
417 410 359 272 161 126 64
461 453 444 428 361 292 146
41
91
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
Antibiotic Exposure in Patients
Receiving Antibiotic Therapy
PCT
Control
Exacerbation of COPD
(n = 228)
Acute Bronchitis
(n = 151)
Patients Receiving
Antibiotic Therapy, %
100
80
60
40
20
0
0
1
2
5
7
9 11 >13
Time After Study Inclusion, d
No. of Patients
PCT
56 47 30 23 16
6
4
2
Control 79 78 67 56 40 20
5
4
PCT: Procalcitoin
COPD: Chronic Obstructive Pulmonary Disease
0
1
16
41
11
38
2
5
7
9 11 >13
Time After Study Inclusion, d
9
35
3
19
3
8
1
3
1
0
1
0
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
Adverse Outcomes
PCT
Control
0
10
20
30
0.2
0.1
0.0
Proportion with Combined
Adverse Outcome
0.1
0.2
CAP (n = 925)
0.0
Proportion with Combined
Adverse Outcome
All Patients (n = 1359)
0
Days Since Randomization
20
30
Days Since Randomization
No. at Risk
PCT
Control
10
No. at Risk
671
688
605
598
579
576
568
558
PCT
Control
460
465
408
396
394
383
386
371
Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.
CONCLUSIONS
• An algorithm with PCT cutoff ranges was noninferior to
clinical guidelines in terms of adverse outcomes in CAP:
• Reduced antibiotic exposure
• Reduced associated adverse effects
• In countries with higher antibiotic prescription rates,
PCT guidance may have clinical and public health
implications
Schuetz P et al. J Am Med Assoc. 2009;302:1059-66.
57
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PROCALCITONIN: CASE STUDIES FROM THE EMERGENCY
DEPARTMENT
58
CASE STUDY- H.C.
•
•
•
•
31 year old female w/ multiple sclerosis on weekly
plasmapheresis
Hospitalized in early July for possible catheter infection
Catheter removed, only 1 blood culture growing coagulase
negative staph.
Transitioned from vancomycin to ofloxacin then to doxycycline
59
CASE STUDY- H.C.
•
•
•
•
Seen in ER June 8 the night of hospital discharge. Patient still
concerned about redness and itchiness near former line site
Given empiric dose of vancomycin after drawing blood cultures,
CBC, PCT.
Discharged home to be followed by PCP and dermatology next
day to determine if broad spectrum antibiotics needed to be
continued.
June 9 dermatology clinic visit suggests patient w/ contact
dermatitis; continues previous course of doxy
60
CASE STUDY H.C.
•
•
Procalcitonin 0.11
PCT level provides reassurance that:
•
•
recurrence of systemic infection unlikely,
present narrow-spectrum antibiotic choice likely effective providing
better antimicrobial stewardship
61
CASE STUDY E.P.
•
•
•
•
•
“classic” PCT benefit case
72 yo male w/ valvular heart disease, sick sinus syndrome s/p
pacemaker* to ED w/ acute SOB on July 8th middle of night shift.
Not known to our system, his primary hospital ER was on bypass,
no old records or previous imaging available
O2, bronchodilators, empiric broad spectrum antibiotics after
blood cultures, labs including PCT
Admitted to intermediate care unit for high flow O2, antibiotics,
monitoring, bronchodilators, trial of diuretics.
*increasing prevalence of elderly patients with pacemakers or on
betablockers reduces clinical vital sign effectiveness in diagnosis SIRS and
Sepsis since heart rate may be artificially blunted
62
CASE STUDY E.P.
•
•
Within 24 hours he required transfer to the ICU and intubation
for respiratory distress and sepsis
PCT was 3.45 from ED draw but due to his nighttime arrival was
not available until after admitted to floor.
63
CASE STUDY E.C.
•
•
•
•
•
•
•
63 yo male w/ fever, chills, atrial fibrillation with RVR (HR 140s)
Treated with diltiazem and broad spectrum antibiotics
Symptoms resolved within two days and patient discharged home
on azithromycin
Emergency department PCT was 0.12
Record review show patient's previous admission for afib with
RVR was attributed to documented influenza A
No virology studies during this admission, only "positive"
microbiological finding was a coag negative staph blood culture
on hospital day 2.
Should patient have had virology screening done even though it
was not flu season?
64
INFORMATION FROM PCT ADDS TO THE QUALITY OF THE CLINICAL
DECISION MAKING
• Understand the kinetics and limitations
of any test in order to optimize its
utilization!
• Guidance of therapy
• Decision on antibiotic initiation
• Guidance of duration of therapy
• Risk stratification of patients
• Admission to hospital
• Admission to ICU
• Escalation of therapy
• Guidance of diagnosis
• More appropriate selection of who might
need invasive diagnostic tests
• Rational utilization of advance imaging
modalities
• Improved direction in choice of microbiology
and virology studies
65
THANK YOU!
QUESTIONS?
COMMENTS?
66