Procalcitonin as a Diagnostic, Therapeutic, and Prognostic Tool: a Critical Review
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Purpose of review
The target of this review is to highlight the current evidence about the utility of procalcitonin (PCT) in different clinical conditions, such as sepsis, respiratory tract infections, urinary tract infections, and bacteremias. The authors aim to discuss the potential benefits and limitations of this biomarker and propose how to safely individualize antibiotic treatment in clinical practice.
Many studies have demonstrated that PCT measurements increase within 6–12 h after bacterial invasion and correlate with disease severity and outcomes of patients with infection. Consequently, they can detect the presence and monitor the status of the bacterial infection, as an objectively and quickly available marker.
PCT-guided algorithms have positive effects in reducing antimicrobial use and mortality, especially in sepsis and respiratory tract infections. However, the adherence to PCT-guided strategies is variable and more studies are needed to validate its regular clinical use on other frequent sites of infections (e.g., skin/soft tissues, bone, CNS) and on specific populations such as immunocompromised patients, since it can be truly recognized as a tool able to reduce antibiotic exposure and costs, improving quality of medical assistance safely.
KeywordsBacterial infections Diagnosis Biomarkers Procalcitonin Stewardship Antibiotic therapy
Compliance with Ethical Standards
Conflict of Interest
Fabrício Torres de Carvalho declares that he has no conflict of interest. Roberto Rabello Filho declares that he has no conflict of interest. Lucas Bulgarelli declares that he has no conflict of interest. Ary Serpa Neto declares that he has no conflict of interest. Rodrigo Octavio Deliberato declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015;19:319. https://doi.org/10.1186/s13054-015-1035-1.CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Hranjec T, Rosenberger LH, Swenson B, Metzger R, Flohr TR, Politano AD, et al. Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study. Lancet Infect Dis. 2012;12(10):774–80. https://doi.org/10.1016/S1473-3099(12)70151-2.CrossRefPubMedPubMedCentralGoogle Scholar
- 26.•• Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M, et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infect Dis. 2018;18:95–107. https://doi.org/10.1016/S1473-3099(17)30592-3 This excellent meta-analysis with 6708 patients showed that the use of procalcitonin to guide antibiotic use in patients with respiratory infections can improve survival and reduce antibiotic exposure and side effects.CrossRefPubMedGoogle Scholar
- 30.Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61–e111. https://doi.org/10.1093/cid/ciw353.CrossRefPubMedPubMedCentralGoogle Scholar
- 33.Bloos F, Trips E, Nierhaus A, Briegel J, Heyland DK, Jaschinski U, et al. Effect of sodium selenite administration and procalcitonin-guided therapy on mortality in patients with severe sepsis or septic shock: a randomized clinical trial. JAMA Intern Med. 2016;176(9):1266–76. https://doi.org/10.1001/jamainternmed.2016.2514.CrossRefPubMedGoogle Scholar
- 34.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. 2010;375(9713):463–74. https://doi.org/10.1016/S0140-6736(09)61879-1.CrossRefPubMedGoogle Scholar
- 35.de Jong E, van Oers JA, Beishuizen A, Vos P, Vermeijden WJ, Haas LE, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomized, controlled, open-label trial. Lancet Infect Dis. 2016;16(7):819–27. https://doi.org/10.1016/S1473-3099(16)00053-0.CrossRefPubMedGoogle Scholar
- 36.•• Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolff M, Chastre J, et al. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care. 2018;22(1):191–202. https://doi.org/10.1186/s13054-018-2125-7 This paper was a meta-analysis focusing on procalcitonin-guided antibiotic management in septic patients and demonstrated that its use can improve survival and decrease antibiotic treatment duration.CrossRefPubMedPubMedCentralGoogle Scholar
- 38.Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA, et al. SAPS 3--from evaluation of the patient to evaluation of the intensive care unit. Part 2: development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med. 2005;31(10):1345–55.CrossRefPubMedPubMedCentralGoogle Scholar
- 42.Schuetz P, Briel M, Christ-Crain M, Stolz D, Bouadma L, Wolff M, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. Clin Infect Dis. 2012;55:651–62. https://doi.org/10.1093/cid/cis464.CrossRefPubMedPubMedCentralGoogle Scholar
- 46.• Schuetz P, Birkhahn R, Sherwin R, Jones AE, Singer A, Kline JA, et al. Serial procalcitonin predicts mortality in severe sepsis patients: results from the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) study. Crit Care Med. 2017;45(5):781–9. https://doi.org/10.1097/CCM.0000000000002321 This multicenter observational clinical trial conducted in 13 emergency departments and ICUs in USA showed that the procalcitonin clearance by more than 80% from baseline to day 4 is a significant independent predictor of mortality in patients with sepsis.CrossRefPubMedPubMedCentralGoogle Scholar
- 49.Schuetz P, Christ-Crain M, Thomann R, Falconnier C, Wolbers M, Widmer I, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302:1059–66. https://doi.org/10.1001/jama.2009.1297.CrossRefPubMedGoogle Scholar
- 53.US Food and Drug Administration. FDA press release. FDA clears test to help manage antibiotic treatment for lower respiratory tract infections and sepsis. 2017. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm543160.htm.
- 57.Wagenlehner FM, Schmiemann G, Hoyme U, Funfstuck R, Hummers-Pradier E, Kaase M, et al. National S3 guideline on uncomplicated urinary tract infection: recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients. Urologe A. 2011;50:153–69. https://doi.org/10.1007/s00120-011-2512-z.CrossRefPubMedGoogle Scholar
- 59.Meier AM, Branche A, Neeser OL, Wirz Y, Haubitz S, Bouadma L, et al. Procalcitonin-guided antibiotic treatment in patients with positive blood cultures: a patient-level meta-analysis of randomized trials. Clin Infect Dis. 2018;25. https://doi.org/10.1093/cid/ciy917.
- 61.Schuetz P, Bolliger R, Merker M, Christ-Crain M, Stolz D, Tamm M, et al. Procalcitonin-guided antibiotic therapy algorithms for different types of acute respiratory infections based on previous trials. Expert Rev Anti-Infect Ther. 2018;16(7):555–64. https://doi.org/10.1080/14787210.2018.1496331.CrossRefPubMedGoogle Scholar