Enhanced Antimicrobial Stewardship with the introduction of Procalcitonin to guide antibiotic duration in Adult Critical Care

Publication: 09/06/2017  
Next review: 02/10/2023  
Clinical Guideline
CURRENT 
ID: 5058 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

SBAR- Enhanced Antimicrobial Stewardship with the introduction of Procalcitonin to guide antibiotic duration in Adult Critical Care

Situation

The prevalence of antimicrobial prescribing is high in critical care patients. There has been a recent increase in the number of sporadic cases of C. difficile infection in this high risk area with root cause analysis investigations suggesting antimicrobial usage has contributed to the infections. While an active antimicrobial stewardship program is in operation on most critical care units, additional measures should be sought to reduce antimicrobial consumption in critical care.

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Background

The utility of Procalcitonin (PCT) as a tool for the diagnosis of sepsis in the critical care setting has been studied with variable results 1-7. The use of PCT in the critical care setting as a tool to guide duration of antibiotics is reported in the literature with a number of good quality randomised control trials and systematic reviews demonstrating reductions in antibiotic consumption and reduced antibiotic treatment costs 8-14. Some studies also demonstrating reduced length of stay10 15. None of these studies cited an increase in complications (such as infection relapse, sepsis or mortality) when employing a PCT guided stewardship program.

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Assessment

PCT monitoring can be used as an adjunct to antimicrobial stewardship to guide duration of antibiotics reducing total duration and cost of antimicrobials.

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Recommendation

A 12 month appraisal in the critical care units in LTHT should commence, assessing the utility of PCT in reducing total antimicrobial consumption. This is to be financially supported by LTHT as part of the strategy to achieve the AMR CQUIN.
During the pilot, the benefits (reduced antibiotic consumption, reduction in antibiotic costs, reduction in C. difficile infection rates) and the risks (worsening sepsis or relapsing infection in patients whose antibiotics were stopped) should be measured.

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Appendix 1

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Provenance

Record: 5058
Objective:
Clinical condition:
Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

  1. Layios N, Lambermont B, Canivet JL, Morimont P, Preiser JC, Garweg C, et al. Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients. Crit Care Med;40(8):2304-9.
  2. Luyt CE, Combes A, Reynaud C, Hekimian G, Nieszkowska A, Tonnellier M, et al. Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia. Intensive Care Med 2008;34(8):1434-40.
  3. McLean AS, Tang B, Huang SJ. Investigating sepsis with biomarkers. BMJ;350:h254.
  4. Saeed K, Dryden M, Bourne S, Paget C, Proud A. Reduction in antibiotic use through procalcitonin testing in patients in the medical admission unit or intensive care unit with suspicion of infection. J Hosp Infect;78(4):289-92.
  5. Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004;39(2):206-17.
  6. Tang BM, Eslick GD, Craig JC, McLean AS. Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 2007;7(3):210-7.
  7. Uzzan B, Cohen R, Nicolas P, Cucherat M, Perret GY. Procalcitonin as a diagnostic test for sepsis in critically ill adults and after surgery or trauma: a systematic review and meta-analysis. Crit Care Med 2006;34(7):1996-2003.
  8. Agarwal R, Schwartz DN. Procalcitonin to guide duration of antimicrobial therapy in intensive care units: a systematic review. Clin Infect Dis;53(4):379-87.
  9. Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, et al. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet;375(9713):463-74.
  10. Hochreiter M, Kohler T, Schweiger AM, Keck FS, Bein B, von Spiegel T, et al. Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial. Crit Care 2009;13(3):R83.
  11. Kopterides P, Siempos, II, Tsangaris I, Tsantes A, Armaganidis A. Procalcitonin-guided algorithms of antibiotic therapy in the intensive care unit: a systematic review and meta-analysis of randomized controlled trials. Crit Care Med;38(11):2229-41.
  12. Liew YX, Chlebicki MP, Lee W, Hsu LY, Kwa AL. Use of procalcitonin (PCT) to guide discontinuation of antibiotic use in an unspecified sepsis is an antimicrobial stewardship program (ASP). Eur J Clin Microbiol Infect Dis;30(7):853-5.
  13. Schroeder S, Hochreiter M, Koehler T, Schweiger AM, Bein B, Keck FS, et al. Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: results of a prospective randomized study. Langenbecks Arch Surg 2009;394(2):221-6.
  14. Stolz D, Smyrnios N, Eggimann P, Pargger H, Thakkar N, Siegemund M, et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study. Eur Respir J 2009;34(6):1364-75.
  15. Nobre V, Harbarth S, Graf JD, Rohner P, Pugin J. Use of procalcitonin to shorten antibiotic treatment duration in septic patients: a randomized trial. Am J Respir Crit Care Med 2008;177(5):498-505.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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