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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 ICU. CPC MRSA. Antimicrobial resistance in ICU.

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A Service Evaluation of Procalcitonin after PRORATA

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  1. A Service Evaluation of Procalcitonin after PRORATA Daniel Cottle DICM John Butler, Tony Dunne, Sanchia Pickering Manchester Royal Infirmary 2011

  2. Antimicrobial resistance in ICU CPC MRSA

  3. 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.

  4. Procalcitonin • Normally produced by the C-cells of the thyroid • Normally undetectable • Unknown role in sepsis • Multiple sources in sepsis • Analgesic

  5. 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

  6. 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

  7. 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

  8. Figure 3 Source: The Lancet 2010; 375:463-474 (DOI:10.1016/S0140-6736(09)61879-1) Terms and Conditions

  9. Methods • Baseline data collection • Protocol • Introduction of protocol • Promote protocol • Reinforce protocol • Data collection • Analysis • Mean (standard deviation) • Student’s t-test

  10. Exclusions • Post bone marrow transplant • Pregnancy • TB, PCJ, toxoplasmosis • Neutropenia • Expected to die

  11. Example Patient 38

  12. Results 60 antibiotic episodes 8 to the ward 4 died 6 exclusions 42 analysed

  13. 42 analysed 4 escalated despite 29 stopped early 1 escalated because 8 no difference

  14. 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

  15. Abdo sepsis • Mean course length 7.9 days • PRORATA: 8.1 days • 4 escalated despite PCT • 1 could have stopped earlier

  16. 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?

  17. QUESTIONS?

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