Chest
Volume 141, Issue 4, April 2012, Pages 1063-1073
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Recent Advances in Chest Medicine
Role of Procalcitonin in Managing Adult Patients With Respiratory Tract Infections

https://doi.org/10.1378/chest.11-2430Get rights and content

Respiratory infections remain the most common reason why patients seek medical care in ambulatory and hospital settings, and they are the most frequent precursor of sepsis. In light of the limitations of clinical signs and symptoms and traditional microbiologic diagnostics for respiratory infections, blood biomarkers that correlate with the presence and extent of bacterial infections may provide additional useful information to improve diagnostic and prognostic efforts and help with therapeutic decisions in individual patients. A growing body of evidence supports the use of procalcitonin (PCT) to differentiate bacterial from viral respiratory diagnoses, to help risk stratify patients, and to guide antibiotic therapy decisions about initial need for, and optimal duration of, therapy. Although still relatively new on the clinical frontier, a series of randomized controlled trials have evaluated PCT protocols for antibiotic-related decision making and have included patients from different clinical settings and with different severities of respiratory infection. In these trials, initial PCT levels were effective in guiding decisions about the initiation of antibiotic therapy in lower-acuity patients, and subsequent measurements were effective for guiding duration of therapy in higher-acuity patients, without apparent harmful effects. Recent European respiratory infection guidelines now also recognize this concept. As with any other laboratory test, PCT should not be used on a stand-alone basis. Rather, it must be integrated into clinical protocols, together with clinical, microbiologic data and with results from clinical risk scores. The aim of this review is to summarize recent evidence about the usefulness of PCT in patients with lower respiratory tract infections and to discuss the potential benefits and limitations of this marker when used for clinical decision making.

Section snippets

PCT for the Diagnosis of Respiratory Infections

Identifying a true “gold standard” for the diagnosis of respiratory infections is often problematic. The use of blood and sputum cultures have significant limitations25, 26 because of the duration of time required to obtain positive cultures and issues of colonization and contamination. Additionally, the inability to grow certain bacteria in standard cultures, as evidenced by the fact that causative microorganisms can be detected in only 10% to 20% of patients with respiratory infections,

PCT for Prognostication in Respiratory Infections

Accurate assessment of disease severity and predictions regarding a patient's clinical course assist patients, families, and caregivers with setting appropriate expectations regarding the illness. These assessments and predictions are also prerequisites for the adequate allocation of health-care resources and therapeutic options in the management of respiratory infections.9 This includes decisions regarding the need for regular hospital or ICU admission, diagnostic evaluation, and assessment

PCT for Therapeutic Decision About Initiation and Duration of Antibiotics

Although timely use of antibiotics is the most effective measure of preventing mortality and morbidity from bacterial respiratory infections, overuse of antibiotics causes considerable harm by exposing individual patients to adverse events including Clostridium difficile infection, by increasing the development of bacterial resistance, and by generating high costs.7, 8 Because of the limitations of traditional signs and symptoms in differentiating viral from bacterial disease, overuse of

Implementation of PCT In the Work-up of Patients With Respiratory Infections

Although further study of PCT in respiratory infections is warranted, it seems reasonable to begin using it clinically, based on the more robust areas of data summarized here. As previously reported, a number of protocols using PCT measurements can now be recommended that consider both clinical severity (based on patient characteristics or level of acuity of care site) and clinical entity (ie, which type of respiratory infection is being considered) to help physicians consider questions of

Costs and Cost-Effectiveness

An important consideration when using a new diagnostic test is the cost associated with the test with respect to the potential for producing a cost saving (the current cost of a PCT test in the United States varies from about $25 to $30). A recent meta-analysis concluded that PCT in the critical care setting may be cost effective because of the high antibiotic costs in critically ill patients.70 Although the same may not necessarily be true for general hospital inpatients with less expensive

Conclusions and Future Directions

It is clear that the use of PCT is not a stand-alone test and will not replace clinical intuition or thorough clinical evaluations of patients.77 PCT needs to be interpreted within the context of the clinical setting and the patient's situation because the correct understanding of PCT levels is predicated on the physician's pretest probability. In this way, it is similar to other markers such as the cardiac troponin or D-dimer. If PCT is embedded in clinical protocols adapted to the type of

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Schuetz was supported by a research grant from the Swiss Foundation for Grants in Biology and Medicine (Schweizerische Stiftung für medizinisch-biologisc Stipendien, PASMP3-127684/1) and received support from BRAHMS Inc and bioMerieux to attend meetings and fulfill speaking engagements. Dr Amin has received support from bioMerieux for speaking engagements. Dr Greenwald has reported

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    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

    Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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