Optimal Use of Procalcitonin for Antimicrobial Stewardship

Background:

Antibiotic misuse is common, a costly problem and leads to development of multi-drug resistant bacteria. The objective was to evaluate the current and future role for procalcitonin (PCT) to guide antimicrobial therapy and whether our intervention had an immediate impact in the Fairview Health System. Our novel approach was a three-part intervention which included a PCT-based antibiotic use protocol, integrated in PCT results in the electronic health record (EHR), face-to-face education to providers, and daily review of patients with PCT test results with real-time advice by the Antibiotic Management Team (AMT).

Methods:

A multi-centered retrospective review was done through data queries of the EHR data for 9817 inpatients, aged 18 years or older, who had PCT tests, encompassing 12699 encounters. The intervention was done Nov 2015 through April 30 2016. The primary outcomes were length of stay (LOS), intensive care unit LOS, antibiotic days of therapy (DOT), (30-day all cause) mortality and readmission of the pre and post-intervention groups. Comparison was done by intervention period at the encounter level. P-value was calculated from generalized estimation equation (GEE) to account for within-patient correlation. LOS and DOT were natural log-transformed due to skewness of the data.

Results:

Procalcitonin has been increasingly ordered over time (figure 1). In the pre and post intervention groups the median LOS decreased from 6 to 5 days (p<0.001), median DOT decreased from 9 to 8 days (p<0.001), mortality decreased from 16.2% to 10.7% (p<0.001), readmission decreased from 26.1% to 22.5% (p<0.001). Comparing the same 6-month period as intervention each year, the 6-month period immediately pre and post intervention does not differ on LOS (p=0.16), DOT (p=0.14), and readmission (p=0.21).

Conclusion:

The number of PCT tests ordered has increased over time. LOS, DOT, mortality, and readmission decreased significantly post intervention. However, the differences of LOS, DOT, and readmission are not observed between the 6-month period immediately pre and post intervention. The next step is to evaluate whether the use of antibiotics, per protocol guidance, improved in the 24 hours post PCT result, after introduction of the PCT algorithm.

Figure 1