Sunday, July 10, 2016

Procalcitonin for Antibiotic De-Escalation in the ICU. Ready for Prime Time?

With the heightened interest given to antibiotic stewardship and de-escalation, I read with great interest this article published in the Lancet Infectious Diseases.

The study was a pragmatic trial, a study design which I fancy, as summarized here. The investigators protocolized the use of procalcitonin levels to aid in antibiotic de-escalation in ICU patients. They reported a 20% reduction in antibiotic use with an unexpected improvement in mortality, something which has yet to be reported.  There are limitations such as the study groups were not blinded and compliance with per protocol antibiotic de-escalation was not super tight. The study is laudable yet not a slam dunk.

Whether interventions such as this can impact antibiotic susceptibility across a healthcare system or even decrease the risk of C. difficile diarrhea is unknown. I would argue that this is the ultimate goal of antibiotic stewardship.

Are we ready to move forward with procalcitonin to guide antibiotic de-escalation? Not yet.

The results are tantalizing but need to be replicated. More pragmatic studies to assess the impact of this strategy for antibiotic stewardship, and, if the results are positive, it would be time to mobilize an effort for changing antibiotic use with protocols utilizing procalcitonin levels. 

Changing physician behavior is challenging enough. To do so with less than truly solid data makes it even that much more difficult, almost impossible.

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