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Procalcitonin: Weighing the Benefits and the Costs · The SHEA Podcast

• 0:09
  SPEAKER_01: Welcome to the Diagnostic Stewardship Podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:26
  SPEAKER_01: Shay is excited to launch the third episode of this podcast series, Procalcitonin Weighing the Benefits and the Costs.
• 0:33
  SPEAKER_01: Procalcetonin is a peptide precursor to the hormone calcetonin.
• 0:37
  SPEAKER_01: Antibiotic stewardship programs have used this diagnostic tool to reduce unnecessary antibiotic use.
• 0:43
  SPEAKER_01: The Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America's guidelines on implementing an antibiotic stewardship program suggests the use of serial procacetonin measurements as an ASP intervention to decrease antibiotic use as a weak recommendation with moderate quality evidence.
• 1:01
  SPEAKER_01: We have two experts here today to discuss the pros and cons associated with incorporating procacetonin into your stewardship program.
• 1:09
  SPEAKER_01: Our two panelists are Dr.
• 1:11
  SPEAKER_01: Shira Darone, an antimicrobial steward and associate hospital epidemiologist at Tufts Medical Center, and Associate Professor of Medicine at Tufts University School of Medicine.
• 1:22
  SPEAKER_01: Here today with Dr.
• 1:23
  SPEAKER_01: Tom File, Chair of the Infectious Diseases Division at SUMA Health, and Professor of Internal Medicine, Master Teacher, and Chair of the Infectious Diseases Section at Northeast Ohio Medical University.
• 1:36
  SPEAKER_01: In addition, he is currently President-elect for the Infectious Diseases Society of America.
• 1:41
  SPEAKER_01: I am Whitney Buckle and I will serve as your moderator.
• 1:44
  SPEAKER_01: I would like to start off this conversation today with a question about time and resources.
• 1:49
  SPEAKER_01: Tom, if you would start, do you feel that implementing procetonin is the best use of time and resources?
• 1:54
  SPEAKER_01: If so, in what patient population do you feel this adds value?
• 1:59
  SPEAKER_00: Well, first of all, Whitney, thanks for inviting me to participate in this podcast.
• 2:03
  SPEAKER_00: But specifically to respond to your question, I think it's hard to argue that it's the best use of resources, but certainly we have found it to be a very good use of resources.
• 2:12
  SPEAKER_00: We have found it to be a very beneficial tool for antimicrobial stewardship.
• 2:17
  SPEAKER_00: And this is because it specifically targets bacterial infections and not inflammation in general.
• 2:23
  SPEAKER_00: And actually it's upregulated, therefore, in bacterial infections and downregulated in viral infections.
• 2:29
  SPEAKER_00: But more specifically, it rapidly responds to the magnitude of a bacterial infection.
• 2:35
  SPEAKER_00: So actually, if we were effectively treating a bacterial infection, we often see the level decrease within hours, or at least six to twelve hours.
• 2:42
  SPEAKER_00: So we first started using uh procalcitonin in our intensive care unit in 2012 and conducted a pilot project uh in one of the floors of our ICU tower and compared antibiotic use and outcomes with another floor without using the procalcitonin test.
• 2:59
  SPEAKER_00: And we subsequently published our findings, which included in the procalcitonin group, a reduction of three days of antibiotics, a reduction of four days of hospitalization, actually, since a lot of patients uh who are not antibiotics don't need to be in the hospital.
• 3:13
  SPEAKER_00: We also saw a reduction, this is very important, uh, in our 30-day readmission rate, and actually had a slight reduction of mortality, although that was not uh statistically significant.
• 3:23
  SPEAKER_00: But certainly we did not harm patients, and that was a concern of some of our colleagues before this project started that we might be stopping antibiotics too early.
• 3:32
  SPEAKER_00: And several individual studies and some meta-analysis have reported uh similar results.
• 3:37
  SPEAKER_00: Now, since then, we've been using the procastotonin extensively whole house, particularly to assist in the decision to discontinue antibiotics.
• 3:46
  SPEAKER_00: So our antibiotic stewardship team frequently recommends the test to provide objective information on top of clinical judgment to stop antibiotics, especially in situations where there may be some uncertainty as to the clinical course of infection.
• 4:01
  SPEAKER_01: Thank you, Tom.
• 4:03
  SPEAKER_01: Shera, what are your thoughts on the use of implementing procalcitonin?
• 4:07
  SPEAKER_02: I also want to thank you for including me in this podcast.
• 4:10
  SPEAKER_02: And I'm really glad you asked about resources, because I think this question of time and resources is really the key to any decision about implementation of procalcitonin in your institution.
• 4:22
  SPEAKER_02: Because implementation of procalcitonin should be done with the realization that it does require additional time and resources from the antimicrobial stewardship program.
• 4:32
  SPEAKER_02: Because that antimicrobial stewardship program team members must be the ones that actively guide the clinicians in interpretation of procalcitonin results if procalcitonin is brought into a hospital.
• 4:43
  SPEAKER_02: I agree with Tom that all of the biomarkers on the market, including any available non-biomarker related scoring systems, procalcitonin makes the most sense.
• 4:55
  SPEAKER_02: But in a study that we did, uh and we looked at a variety of biomarkers and Apache scores, all performed equally poorly at distinguishing sepsis from non-infectious SERS like signs and symptoms.
• 5:08
  SPEAKER_02: In my opinion, the same resources that would be used to make procalcitonin effective could be used for stewardship interventions like improving adherence to guidelines and in particular decreasing the duration of antibiotic use or ensuring the appropriate duration of antibiotics according to guidelines.
• 5:29
  SPEAKER_02: So, in a study in OSID in 2019 by Yadav et al.
• 5:34
  SPEAKER_02: they addressed the fear that's associated with decreasing or stopping antibiotics too early, and they reported on the use of this concept of expected practice, and they demonstrated that just by using strict guidelines on duration alone, they were able to see significant decreases in antibiotic days for a variety of infections.
• 5:53
  SPEAKER_02: And coincidentally, in their hospital, procalcitonin was brought on board at around the same time.
• 5:58
  SPEAKER_02: And when they looked specifically at patients in whom procalcitonin was used and not used, they actually showed an increased duration in those patients in whom procalcitonin was used.
• 6:08
  SPEAKER_02: Whereas overall the expected practices decreased duration.
• 6:11
  SPEAKER_02: So at my hospital, we've chosen to use our resources to make recommendations to stop therapy based on clinical factors.
• 6:18
  SPEAKER_02: And because we have a very good relationship with our clinicians, that has been effective.
• 6:22
  SPEAKER_02: So we haven't felt that procalcitonin is the way to go for us in terms of resources.
• 6:28
  SPEAKER_00: You know, if I can follow up what Sure said, I certainly agree that the clinical stability of a patient is is paramount in when we stop antibiotics.
• 6:35
  SPEAKER_00: And there's been actually significant uh evidence added in the last decade about optimal duration of antibiotics in specific infections.
• 6:42
  SPEAKER_00: For example, for comedic choir pneumonia, we now know five days is what is appropriately and recommended according to guidelines, and for HAP VAP, it's uh for seven days, and actually treating beyond that, we're probably harming patients more than than we're helping.
• 6:56
  SPEAKER_00: But uh Shira knows, I mean, many studies have documented that uh we use uh antibiotics too long for many infections.
• 7:03
  SPEAKER_00: Actually, uh there was a recent study just published uh last month on the Annals of Internal Medicine evaluating the treatment of patients in the hospital for communicating pneumonia, finding that they were actually many of them were being treated uh too long.
• 7:16
  SPEAKER_00: And certainly it's important for us to uh go by these uh evidence-based recommendations.
• 7:21
  SPEAKER_00: However, in our experience, maybe a significant percentage of patients, maybe 25-30 percent, have some degree of uncertainty regarding the clinical response and and reaching clinical stability within a preset duration.
• 7:35
  SPEAKER_00: And much of this uncertainty may be due to comorbid conditions, not necessarily to the infection itself.
• 7:40
  SPEAKER_00: I mean, for example, there may be persistent dyspia, shortness and breath or whatever, due to congestive heart failure or underlying pulmonary disease rather than due to the pneumonia.
• 7:50
  SPEAKER_00: So in these cases, particularly, we found the proceletonin to be helpful to stop the antibiotics, even though there's uncertainty about the clinical stability.
• 7:59
  SPEAKER_01: Thank you.
• 8:00
  SPEAKER_01: I think this is a great discussion already, and I appreciate the two perspectives.
• 8:04
  SPEAKER_01: It sounds like procetonin is a tool that really depends on the institution that you are practicing in and where it can add the most value.
• 8:13
  SPEAKER_01: I suspect one thing that we all agree on is that any diagnostic tests can be used inappropriately.
• 8:18
  SPEAKER_01: Have you seen procacetonin used inappropriately?
• 8:22
  SPEAKER_01: If so, can you provide any examples?
• 8:24
  SPEAKER_00: Well, I guess I'll start with that, but uh let me just say that in order to use uh any of these tests, particularly procacetonin appropriately, we need to be aware of what the appropriate threshold or cutoffs are uh to interpret them.
• 8:37
  SPEAKER_00: And fortunately, a recent consensus paper was published uh whereby a group of experts have recommended a cutoff of 0.25 for mild to moderate infections and 0.5 for uh severe infections to sort of differentiate bacterial versus non-bacterial processes.
• 8:53
  SPEAKER_00: Now, in addition, they also indicate that if there's been a reduction of the procalcitonin level, let's say 80 to 90 percent, and let's say example from 10 to 1 or 2, that you don't need to be below 0.5 or 0.25, that their evidence indicates that it's safe to stop antibiotics, of course, when there's stability.
• 9:12
  SPEAKER_00: In addition, we need to be aware of the limitation of the test, and really we should be using the test to supplement our clinical judgment rather than obviously dictate it.
• 9:21
  SPEAKER_00: And we need to be aware that test is likely to be low in very early bacterial infections.
• 9:26
  SPEAKER_00: I mean, we've seen patients come in with sepsis or transferred to our ICU with sepsis, and it'll be low initially, but then 12 hours later it'll be quite high.
• 9:35
  SPEAKER_00: And the test is uh also likely to be low in some chronic infections, including SBE, and certainly not good for non-systemic uh local infections, for example, cystitis versus pylonophritis.
• 9:48
  SPEAKER_00: And then we have to be aware of so-called false positives, which really aren't false positives, but in the situations where the test may be elevated and there's not a bacterial infection.
• 9:58
  SPEAKER_00: And examples would be it can be elevated in patients with renal impairments or in non-septic shock where there's hypoperfusion of the gastrointestinal tract and therefore release of cytokines that can stimulate procalcitonin.
• 10:11
  SPEAKER_00: In fact, these are potential examples where an elevated procalcitonin may be inappropriately interpreted to continue antibiotics when in fact there may not be a bacterial infection present.
• 10:21
  SPEAKER_01: Thanks, Tom, for those examples.
• 10:24
  SPEAKER_01: Sherrod, do you have some examples of where you've seen procalcytonin use inappropriately?
• 10:29
  SPEAKER_02: We don't use procalcitonin in my hospital, but I have heard anecdotally and seen firsthand some examples of inappropriate use.
• 10:37
  SPEAKER_02: There is a facility for whom I do telestewardship.
• 10:41
  SPEAKER_02: And when I and my colleagues came on board for them, we noticed that their clinicians were accustomed to sending daily procalcitonins on most patients with a diagnosis of bacterial infection, and that they typically would keep patients on antibiotics for very long durations, much longer than would be appropriate based on guidelines, particularly when we're talking about ventilator-associated pneumonia, where the guidelines are very clear.
• 11:12
  SPEAKER_02: The newest guidelines say that antibiotics should be continued for seven days.
• 11:16
  SPEAKER_02: If procalcitonin is used, that could, and I've seen it often result in much longer durations of antibiotics as a result of the level not reaching that threshold for discontinuation.
• 11:29
  SPEAKER_02: I've heard other anecdotes from people at other hospitals reporting very large cost expenditures at their hospitals on the order of hundreds of thousands of dollars annually.
• 11:42
  SPEAKER_02: And so, as we've said before, it's really important to utilize resources properly so that it doesn't become simply a financial liability.
• 11:50
  SPEAKER_02: Recently heard a story of a patient who was seen in the outpatient setting with pineylandformitis deemed to be stable to go home, given oral antibiotics was doing better.
• 12:00
  SPEAKER_02: But when the outpatient physician checked the labs at some point in the next 24 hours, the procalcitonin had come back and it was high, and the patient was called to be admitted even though they were perfectly well.
• 12:13
  SPEAKER_02: So I think there's a danger that if clinicians don't really understand the nature of the test result and how to use it, there can be inappropriate conclusions that are made and inappropriate care provided.
• 12:27
  SPEAKER_00: Yeah, I certainly agree with that.
• 12:28
  SPEAKER_00: And uh I find that this is where our antibiotic stewardship team is very helpful in helping to interpret and therefore provide appropriate interventions.
• 12:37
  SPEAKER_00: Because I might counter the studies that have shown an increase in cost.
• 12:40
  SPEAKER_00: There's actually a couple of studies that were just recently published in the last several months showing that if you appropriately use the procalceton in conjunction with uh clinical stability and with an oversight by an antimicrobial stewardship team, you actually can reduce uh hospital costs.
• 12:56
  SPEAKER_00: So I think the message here is that we need to appropriately uh interpret it and have a good antimicrobial stewardship team that helps out in that interpretation and appropriate recommendations.
• 13:08
  SPEAKER_01: I think that's a great point.
• 13:10
  SPEAKER_01: I know that the IDSA and SHA guidelines state that antimicrobial stewardship programs must develop processes and guidelines to assist clinicians because this test can be used suboptimally.
• 13:20
  SPEAKER_01: It's worthwhile to educate or integrate into the electronic medical record.
• 13:26
  SPEAKER_01: Tom, I know you've implemented this at your hospital.
• 13:28
  SPEAKER_01: Do you have any recommendations or can share how you implemented procastitonin?
• 13:34
  SPEAKER_00: Well, we do sort of prospective evaluation uh with our antimicrobial stewardship team, and when we look at the results of the test, we actually contact the physicians who are involved in that uh case, and so we do a face-to-face discussion with the clinicians about how the test should be interpreted, and then we can give the appropriate recommendations uh for uh interventions, and we find that the best way so that it actually allows us to do real-time education about how to use this test.
• 14:02
  SPEAKER_00: We also every year go to every one of our departments and talk to the residents and talk to the attending physicians about a variety of tests, including the procalcitonin and how it is appropriately interpreted.
• 14:13
  SPEAKER_00: But uh, I guess the bottom line is that we in our antimicrobial stewardship team actually intervene and interpret the test to so that we give the appropriate recommendations.
• 14:24
  SPEAKER_02: I agree with all of that, and I think with any new test on the market, frequent reminders that clinical judgment supersedes the importance of the test results is really important.
• 14:36
  SPEAKER_02: And, you know, this is really analogous to some of the things that we've been saying about all of the many infectious disease rapid diagnostic tests on the market, which are highly sensitive and sometimes uh not as specific as we would like them to be.
• 14:49
  SPEAKER_02: We really need to use our clinical judgment and remember that the clinical scenario in front of us is much more important than the test results.
• 14:58
  SPEAKER_02: I do question to what extent in some of these studies that show decreased antibiotic duration might be measuring the utility of an algorithmic approach as opposed to the test itself, because in all of the studies that were successful, they had a very strict algorithm that the clinicians followed.
• 15:16
  SPEAKER_02: And if one had such a strict algorithm simply for the care of the patient and the duration of the antibiotics, would they have been as successful?
• 15:25
  SPEAKER_01: I agree.
• 15:26
  SPEAKER_01: I think this is a great discussion.
• 15:28
  SPEAKER_01: Because concomitant education appears to be so valuable, why don't we end on one last question about key educational points?
• 15:36
  SPEAKER_01: With our remaining minutes, are there any key educational points that you feel are important to emphasize or that are often overlooked with procytonin?
• 15:45
  SPEAKER_00: Well, I think both of us have said this that any of these tests, including the procalcetonin, should not replace clinical judgment, but it can be a valuable tool in assisting uh clinical judgment on the discontinuation of antibiotics.
• 15:58
  SPEAKER_00: And I guess I'll end with the fact that antimicrobial resistance is a public health crisis.
• 16:03
  SPEAKER_00: And we know uh at least certain experts have warned that if current trends continue, that more people will die annually from infections due to antimicrobial resistant pathogens and from cancer.
• 16:14
  SPEAKER_00: I mean, this is a really important issue.
• 16:16
  SPEAKER_00: And we also know that the most significant predisposing factor for selecting resistance is the use of antibiotics, often inappropriate use.
• 16:24
  SPEAKER_00: So my feeling, I guess, is that any test that can help promote reduced use of antibiotics is a welcome and useful test, and that's how I feel about procalcetona.
• 16:34
  SPEAKER_02: I agree.
• 16:35
  SPEAKER_02: Anything that can decrease the duration of antibiotics or the inappropriate initiation of antibiotics is a useful test, uh, for sure.
• 16:43
  SPEAKER_02: And each facility needs to determine the best way to implement new technology in such a way as to make that the outcome, and to make sure that when implementing a new test, it isn't resulting in the opposite of what one intends, i.e., overuse of antibiotics or overdiagnosis of infection.
• 17:01
  SPEAKER_02: So anything that does it right is a great addition to the R momentarium in my book.
• 17:06
  SPEAKER_01: That is a great note to end on.
• 17:08
  SPEAKER_01: Thank you to our panelists, Dr.
• 17:11
  SPEAKER_01: Shirid Darone and Dr.
• 17:13
  SPEAKER_01: Tom Pile, for sharing your perspective and experiences.
• 17:17
  SPEAKER_01: Looking to expand your knowledge and diagnostic stewardship, then join us at the Sixth International Conference on Healthcare Associated Infections Decennial 2020.
• 17:27
  SPEAKER_01: This conference will be held in Atlanta, Georgia from March 26th through the 30th, and is co-hosted by Shay and the CDC.
• 17:35
  SPEAKER_01: Find out more at www.decennial2020.org.
• 17:40
  SPEAKER_01: Thank you again.
• 17:40
  SPEAKER_01: This concludes the third episode of the Diagnostic Stewardship Podcast Series.
• 17:45
  SPEAKER_01: Keep an eye out for our fourth and final podcast, GI Biofire Film Array essay.
• 17:51
  SPEAKER_01: We've got a test and a result now what?