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A Service Evaluation of Procalcitonin after PRORATA. Daniel Cottle DICM John Butler, Tony Dunne, Sanchia Pickering Manchester Royal Infirmary 2011. Antimicrobial resistance in ICU. CPC MRSA. Antimicrobial resistance in ICU.

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a service evaluation of procalcitonin after prorata

A Service Evaluation of Procalcitonin after PRORATA

Daniel Cottle DICM

John Butler, Tony Dunne, Sanchia Pickering

Manchester Royal Infirmary 2011

antimicrobial resistance in icu1
Antimicrobial resistance in ICU

Reducing antibiotic use may contain the emergence of multi-drug resistance bacteria in ITUs.

Stop inappropriate prescribing.

Shorten duration of treatment of antibiotics.

  • Major factor affecting patient outcome and resources.
  • Insufficient infection control measures.
  • Selective antibiotic pressure.
procalcitonin
Procalcitonin
  • Normally produced by the C-cells of the thyroid
  • Normally undetectable
  • Unknown role in sepsis
  • Multiple sources in sepsis
  • Analgesic
slide5
Procalcitonin – in relevant bacterial infection produced and released into circulation from the whole body

Calcitonin in healthy persons

PCT in bacterial infection

PCT

Calcitonin

Müller B. et al., JCEM 2001

www.procalcitonin.com

procalcitonin kinetics
Procalcitonin- Kinetics

Fast increase of PCT after bacterial challenge

Brunkhorst FM et alIntens Care Med 1998; 24:888-892

  • Fast increase (after 3-4 hours), high dynamic range
  • Wide concentration range < 0.05 ng/ml - 1000 ng/ml
  • Short half-life time (~ 24 h) independent of renal function
  • Easy to measure in serum and plasma - stable in vivo and in vitro
prorata lancet 2010
PRORATA Lancet 2010
  • Multicentre, randomised, controlled trial.
  • 311 procalcitonin, 319 control.
  • Days without antibiotics:
    • 14.3 days PCT : 11.6 control.
  • The mean duration of the first episode of antibiotics was reduced from 9.9 days to 6.1 days, AR 3.8 days; 95% CI 2.7-4.8, p<0.0001
  • No increase in mortality
slide8

Figure 3

Source: The Lancet 2010; 375:463-474 (DOI:10.1016/S0140-6736(09)61879-1)

Terms and Conditions

methods
Methods
  • Baseline data collection
  • Protocol
  • Introduction of protocol
  • Promote protocol
  • Reinforce protocol
  • Data collection
  • Analysis
  • Mean (standard deviation)
  • Student’s t-test
exclusions
Exclusions
  • Post bone marrow transplant
  • Pregnancy
  • TB, PCJ, toxoplasmosis
  • Neutropenia
  • Expected to die
results
Results

60 antibiotic episodes

8 to the ward

4 died

6 exclusions

42 analysed

slide14

42 analysed

4 escalated despite

29 stopped early

1 escalated because

8 no difference

chest sepsis
Chest sepsis
  • Mean course length 5.5 days
  • PRORATA: CAP 5.5 days, VAP 7.7 days
  • 8 had a starting PCT <0.5
  • 3 could have stopped earlier
abdo sepsis
Abdo sepsis
  • Mean course length 7.9 days
  • PRORATA: 8.1 days
  • 4 escalated despite PCT
  • 1 could have stopped earlier
conclusions
Conclusions
  • PCT reduced antibiotic use on our unit
  • Definite end-point
  • More structured approach
  • Could this be reduced further?
  • PCT <0.5 as a rule out?