PROCALCITONIN: ADVANCING DECISION MAKING IN SEPSIS

Sean-Xavier Neath, M.D., Ph.D.Assistant Clinical Professor of MedicineDepartment of Emergency MedicineUniversity of California, San Diego

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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 non-bacterial 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

3

DISCLOSURES

1) Consultant relationships with biomedical companies working on biomarkers in acute disease states

Thermo Fisher ScientificBRAHMS

2) Employed by the University of California, San Diego Medical Center as an Assistant Professor of Clinical Medicine, Department of Emergency Medicine

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WHAT IS SEPSIS?

• Whole Body Inflammatory State plus Infection

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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.

6Slide

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.

InfectionInfection

ParasiteParasite

VirusVirus

FungusFungus

BacteriaBacteriaTraumaTrauma

BurnsBurns

SepsisSepsis SIRSSIRSSevereSevereSepsisSepsis

SevereSevereSIRSSIRS

Adapted from SCCM ACCP Consensus Guidelines

shock

BSIBSI

8

Martin GS et al. NEJM 2003;348:1346

POPULATION ADJUSTED INCIDENCE OF SEPSIS (USA)

9

Martin GS et al. NEJM 2003;348:1346

CASES OF SEPSIS BY PATHOGEN (USA)

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INFECTION SOURCE IN SEVERE SEPSIS

44.0%

17.3%9.1%

8.6%

6.6%

2.2%

8.0%

6.0%

10.8%Respiratory

Bacteremia

GU

Abdomen

Soft tissue

Device

CNS

Endocarditis

Other

Angus DC et al. Crit Care Med. 2001; 29:1303

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DETERMINANTS OF MORTALITY

• Source control is most vital factor• Resuscitation/re-establish perfusion in 6 hrs• Appropriate antibiotic therapy within 1 hr of hypotension

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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

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• 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

DIFFICULTIES IN DIAGNOSIS AND TREATING SEPSIS IN THE EMERGENCY DEPARTMENT

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• 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

DIFFICULTIES IN DIAGNOSIS AND TREATING SEPSIS IN THE EMERGENCY DEPARTMENT

15 Kumar A. et al., Crit Care Med 2006, 34:1286

DURATION OF HYPOTENSION BEFORE INITIATION OF EFFECTIVE ANTIMICROBIAL THERAPY IS THE CRITICAL DETERMINANT OF SURVIVAL IN HUMAN SEPTIC SHOCK

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FAILURE TO INTERVENE QUICKLY CAN BE FATAL

Sebat CCM 2007; 35: 2568

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• Initial Resuscitation• Diagnosis• Antibiotic therapy• Source Control• Fluid therapy• Vasopressors• Inotropic Therapy• Steroids• Recombinant Human Activate

d 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

Key Areas of Sepsis Management

Dellinger, et. al. Crit Care Med 2004, 32: 858-873.

ROLE OF PROCALCITONIN IN INITIAL SEPSIS MANAGEMENT

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WHY PROCALCITONIN?

Integrated use of PCT with other clinical and laboratory informationpermits:•Increased accuracy of clinical diagnosis of relevant bacterial infection / sepsis

•Improved clinical decision making and patient management

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• 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

PROCALCITONIN – A BIOMARKER FOR THE ASSESSMENT OF CRITICALLY ILL PATIENTS AT RISK FOR SEVERE BACTERIAL INFECTION AND SEPSIS

Morgenthaler N. et al., Clin Lab 2002, 48: 263-270

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PROCALCITONIN – NORMALLY AN INTERMEDIATE PRODUCT IN THE SYNTHESIS OF CALCITONIN

N-Pro Calcitonin Katacalcin

N C

1 57 60 91 96 116

After P. Linscheid, Endocrinology 2003

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

Thyroid

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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

PROCALCITONIN – PRESENCE OF BACTERIAL INFECTION STIMULATES PCT PRODUCTION

Adapted from Christ-Crain et al. 2005

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Calcitonin: Sources ofproduction in healthy

people

Müller B. et al., JCEM 2001

• In bacterial infection, PCT is produced and released into circulation from the entire body

HIGHLY SPECIFIC INDUCTION AND RELEASE OF PCT DUE TO BACTERIAL INFECTION

Healthy Sepsis

PCT:Sources of Productionin Septic Patients

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• 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

PCT LEVEL INCREASE = INCREASED SIGNIFICANCE OF BACTERIAL INFECTION

Healthy Individuals

Local Infections

Systemic Infections (Sepsis)

Severe Sepsis

Septic Shock

0.05 ng/ml

0.5 ng/ml

2 ng/ml

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• IFN- released in viral infection, blocks the activation of PCT production, therefore in viral infection PCT levelsremain normally low

HIGHLY SPECIFIC INDUCTION AND RELEASE OF PCT DUE TO BACTERIAL INFECTION

Adapted from Christ-Crain et al. 2005

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Easy to measure, not invasive, relatively inexpensiveBiomarker Testing (PCT)

Slow kinetics , high impact of inflammation (specificity), suppressed by corticosteroids, relatively inexpensive

BENEFITS AND LIMITATIONS OF OTHER SEPSIS DIAGNOSTIC TOOLS

Microbiology (Blood Culture)

Imaging (X-Ray, Hr-CT)

Molecular Biological Testing

Biopsy

C-Reactive Protein (CRP)

Standard of care, time to result, ?Sens., ? Spec.

Availability, costs, variability of source detection

Invasive, relatively expensive

Availability, costs, time to results

27Simon L. et al. Clin Infect Dis. 2004; 39:206-217.

• 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

DIAGNOSTIC ACCURACY OF PCT COMPARED TO OTHER BIOMARKERS USED IN SEPSIS

Sensitivity: 89%Specificity: 94%

NPV: 90% / PPV: 94%

28Harbarth S et.al. AM J Resp Crit Care Med. 2001; 164:396-402

• When PCT is used as a reference, the sensitivity and specificity of sepsis diagnosis can be significantly increased compared with conventional clinical parameters.

ADDING PCT RESULTS TO CLINICAL ASSESSMENT IMPROVES THE ACCURACY OF THE EARLY CLINICAL DIAGNOSIS OF SEPSIS

AUC with PCT: 0.94AUC without PCT: 0.74

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• 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

PCT LEVELS INCREASE ACCORDING TO SEVERITY OF SEPSIS

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

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• PCT used in early detection of infection after liver transplantation – differentiation from rejection

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 Liver-Transplantation, Tx: day of transplantation.

PCT plasma concentrations in infection and rejection (n = 11), day 0: day of diagnosis

Kuse ER et al., Crit Care Med 2000; 28: 555-559

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• 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

PCT KINETICS PROVIDE IMPORTANT INFORMATION ON PROGNOSIS OF SEPSIS PATIENTS

Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892

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INTERPRETING PROCALCITONIN VALUES

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• 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.

PCT RELEASE IN THE ABSENCE OF INFECTION

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INFECTEDUNINFECTED

C Chiesa et al. CID 1997

• 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.

ADDING PCT RESULTS TO CLINICAL ASSESSMENT IMPROVES THE ACCURACY OF THE EARLY CLINICAL DIAGNOSIS OF SEPSIS IN NEONATES

Time (hours) Time (hours)

PCT (ng/ml)

PCT (ng/ml)

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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

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• PCT values must always be interpreted within the clinical context of each individual patient

• Serial measurement is preferred to assess the situation in real-time

• 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)

INTERPRETATION OF PCT LEVELS

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• 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

PCT KINETICS AFTER AN INFECTIOUS CHALLENGE

Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892

Brunkhorst FM et al., Intens. Care Med (1998) 24: 888-892

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• 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

PCT REFLECTS THE RESPONSE OF THE ORGANISM TO THE BACTERIAL CHALLENGE

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PROCALCITONIN UTILIZATION TO IMPROVE PATIENT CARE IN THE HOSPITAL

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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 coagulase-negative staphylococci

• At a cut-off of 0.1ng/ml sensitivities and specificities were

• Day –1 of BC: 86% and 60%• Day 0 of BC: 100% and 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

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• 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.

PCT LEVELS PREDICT BACTEREMIA IN PATIENTS WITH COMMUNITY ACQUIRE PNEUMONIA (CAP)

Muller et al. CHEST July 2010

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PCT PREDICTS BACTEREMIA IN PATIENTS WITH CAP: PATIENT FLOW IN DERIVATION AND VALIDATION COHORTS

Muller et al. CHEST July 2010

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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

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• 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.

PCT LEVELS PREDICT BACTEREMIA IN PATIENTS WITH COMMUNITY ACQUIRE PNEUMONIA

Muller et al. CHEST July 2010

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Mortality by PCT level

0%

2%

4%

6%

8%

10%

12%

0 5 10 15 20 25 30

Day

Mo

rtal

ity,

%

≥ 0.1

< 0.1

Huang, et.al., Annals of Emergency Medicine, Vol 51, March 2008

• 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).

PCT RESULTS PROVIDE IMPORTANT INFORMATION ON PROGNOSIS OF CAP PATIENTS IN EMERGENCY ROOM

PCT

PCT

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• 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

SERIAL MEASUREMENT OF PCT PROVIDES A CLEARER PICTURE OF THE PATIENT’S RESPONSE TO ANTIBIOTIC TREATMENT.

Stueber, F. University of Bonn, Lecture at ISICEM, Brussels 2001

48Nobre V. et alAM Resp Crit Care Med 2008: 177:498-505

• Effect of PCT-guided management in patients with sepsis on ICU length of stay

PCT GUIDANCE IN ANTIBIOTIC USAGE EFFECTS ON LENGTH OF STAY

49Nobre V. et alAM Resp Crit Care Med 2008: 177:498-505

• Effect of PCT-guided management in patients with sepsis on ICU length of stay

PCT GUIDANCE ON EFFECT ON LENGTH OF ICU STAY

50Nobre V. et al AM Resp Crit Care Med 2008: 177:498-505

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

PCT GUIDANCE IN ANTIBIOTIC USAGE HAS BEEN SHOWN TO SIGNIFICANTLY SHORTEN THE TIME PATIENTS NEED TO BE ON ANTIBIOTICS

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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

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Schuetz P et al. J Am Med Assoc. 2009;302:1059-66.

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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

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Schuetz P et al. J Am Med Assoc. 2009;302:1059-66.

53

RATES OF COMBINED ADVERSE OUTCOMES AND MORTALITY BY RANDOMIZATION GROUP

No. (%) of Patients

PCT Control Risk Difference, % Group Group Group (95% CI)

All patients (intention-to-treat) (n = 671) (n = 688)

Overall adverse outcome 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)

Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.

0

Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.

Antibiotic Exposure in Patients Receiving Antibiotic Therapy

All Patients (n = 1359)

Community-acquired Pneumonia (n = 925)

Patie

nts

Rece

ivin

g An

tibio

tic T

hera

py, %

20

40

60

80

100

Time After Study Inclusion, d Time After Study Inclusion, d0 1 2 5 7 9 11 >13

No. of Patients PCT 506 484 410 306 207 138 72 46 Control 603 589 562 516 420 324 157 100

417 410 359 272 161 126 64 41461 453 444 428 361 292 146 91

0 1 2 5 7 9 11 >13

PCTControl

Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.

Antibiotic Exposure in Patients Receiving Antibiotic Therapy

0

Patie

nts

Rece

ivin

g An

tibio

tic T

hera

py, %

20

40

60

80

100

Time After Study Inclusion, d0 1 2 5 7 9 11 >13

Time After Study Inclusion, d0 1 2 5 7 9 11 >13

Exacerbation of COPD (n = 228)

Acute Bronchitis (n = 151)

No. of Patients PCT 56 47 30 23 16 6 4 2 Control 79 78 67 56 40 20 5 4

16 11 9 3 3 1 1 141 38 35 19 8 3 0 0

PCT: ProcalcitoinCOPD: Chronic Obstructive Pulmonary Disease

PCTControl

All Patients (n = 1359)

Prop

ortio

n w

ith C

ombi

ned

Adv

erse

Out

com

e

0 10 20 30

0.0

0.1

0.2

Days Since Randomization

No. at Risk

PCTControl

671 605 579 568688 598 576 558

CAP (n = 925)

Prop

ortio

n w

ith C

ombi

ned

Adv

erse

Out

com

e

0 10 20 30

0.0

0.1

0.2

Days Since Randomization

No. at Risk

PCTControl

460 408 394 386465 396 383 371

Adverse Outcomes

PCTControl

Schuetz P et al. J Am Med Assoc. 2009;302(10):1059-66.

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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

57

Schuetz P et al. J Am Med Assoc. 2009;302:1059-66.

58

PROCALCITONIN: CASE STUDIES FROM THE EMERGENCY DEPARTMENT

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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

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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

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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

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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

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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.

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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?

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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

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THANK YOU!

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