SLR - October 2014 - Matthew M. Reiner
Procalcitonin-Guided Therapy in Intensive Care Unit Patients with Severe Sepsis and Septic Shock-Systematic Review and Meta-Analysis
Reference: Prkno A, Wacker, C, Brunkhorst FM, Schlattmann P. Procalcitonin-Guided Therapy in Intensive Care Unit Patients with Severe Sepsis and Septic Shock—A Systematic Review and Meta-Analysis. Crit Care 2013, 17: R291.
Scientific Literature Review
Reviewed By: Matthew M. Reiner, DPM
Residency Program: Saint Vincent Charity Medical Center, Cleveland, Ohio
Podiatric Relevance: Multiple factors must be taken into account when risk stratifying critically ill patients. While clinical exam is the most important tool, other markers for sepsis such as vitals, white blood cell count, erythrocyte sedimentation rate, and c-reactive protein are essential. Many institutions now employ procalcitonin for early diagnosis of sepsis and duration of antibiosis. While the use of procalcitonin guided therapy antibiosis can play a vital role in limiting potentially harmful consequences, it may also be useful for the podiatrist in an inpatient setting. This biomarker can also be used to determine severity of infection in a limb salvage situation. It has a short induction after bacterial stimulus and long half life all making it an important tool to include in when ordering infection labs. It is important to note it does not respond to local bacterial infection, viral infection, or autoimmune and allergic disorders.
Methods: Eligible studies had to be randomized controlled clinical trials or cohort studies which compared procalcitonin guided therapy with standard care in severe sepsis patients at least one of the following outcomes: hospital mortality, 28-day mortality, duration of antimicrobial therapy, length of stay in ICU or length of hospital stay. A total of seven studies with 1,075 patients were included.
Results: Hospital and 28-day mortality rate were not different between procalcitonin-guided therapy and standard treatment groups. Duration of antimicrobial therapy was significantly reduced in favor of procalcitonin guided therapy. Many authors had differing but similar recommendations for antibiosis based on level of procalcitonin and overall trend. There was no difference in combined estimates for length of stay in ICU or hospital.
Conclusion: The use of a procalcitonin guided therapy reduced antibiotic therapy by two days. Combining this information with clinical judgment could help minimize complications seen with antibiotic therapy and establish a guideline for treatment of sepsis. Another benefit is reducing antimicrobial resistance seen when using broad-spectrum antibiotics. A weakness of this meta-analysis was differing de-escalation and escalation treatment protocols based on peak or initial procalcitonin values and serial monitoring. There is no consensus on proper value for procalcitonin as most authors utilize this in concert with clinical judgment. Future studies involving procalcitonin would be beneficial in determining presence of a necrotizing soft tissue infections and optimal level of amputation. Currently, procalcitonin serves as another important tool in management of diabetic or complicated lower extremity infections in the hospital setting whether it be medically and/or surgically.