Using biomarkers such as procalcitonin (PCT) in the ER can help physicians assess the risk for sepsis before patients are admitted to the ICU.
The Society of Critical Care Medicine recently updated its sepsis guidelines, recommending early empirical broad-spectrum antibiotics that are then adjusted or de-escalated as more information becomes available.
“The early identification of sepsis is important to initiating appropriate therapy as soon as possible, which mitigates the immune response, organ injury and other problems that occur when patients become septic,” explained Lucas Schulz, PharmD, BCPS, at the University of Wisconsin Health Department of Pharmacy, in Madison.
While the gold standard for identifying an infection remains culture, results take a minimum of 24 hours, and if sensitivity data are needed, much longer. The FDA recently expanded the clinical claims of the B-R-A-H-M-S PCT (Thermo Fisher Scientific) assay for sepsis risk assessment. In about 20 minutes, the assay measures for PCT, a sensitive and specific inflammatory biomarker that is elevated only in the presence of bacteria.
Therefore PCT quickly identifies an infectious process, which can begin to inform treatment, according to Dr. Schulz. “The earlier antimicrobials are started, the earlier one can reduce the SIRS [systemic inflammatory response syndrome] and affect the physiology of sepsis,” he said.
Clinicians can use PCT to help assess the response of septic patients to treatment by comparing a baseline PCT measurement with a PCT value taken every 24 hours to assess response to therapy, explained Mike Broyles, PharmD, the director of pharmacy and laboratory services at the Five Rivers Medical Center, in Pocahontas, Ark. The change in PCT over time, with other laboratory findings and clinical assessments, can help predict patient response, he noted.
That was the basis for the FDA’s expanded clearance for the B-R-A-H-M-S PCT assay. A multicenter study investigated the relationship between a decrease in PCT levels over the first four days in the hospital and outcomes in patients diagnosed with severe sepsis or septic shock. The researchers followed 858 adult patients, across 13 sites, who were diagnosed with severe sepsis or septic shock in an ICU, ER or medical ward before ICU admission. Patients showing a decrease in PCT of 80% or less during the first four days after diagnosis had a twofold increased risk for death compared with those who experienced a decrease in PCT of greater than 80%.
“Sepsis is responsible for more than 1.6 million hospital stays with a high mortality rate,” said lead principal investigator Nathan I. Shapiro, MD, MPH, an attending physician in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center, in Boston. “Given this reality, there is a need for additional tools to support informed decisions regarding care of patients suspected of or diagnosed with sepsis.”
In a poster presented at IDWeek 2016, researchers from the Fairview Health System in Minnesota conducted a retrospective review of PCT throughout their hospitals. They reviewed the electronic health records from November 2015 through April 30, 2016, to see how the hospital was using a PCT and its effects on patient care. PCT testing was ordered for 9,817 adult patients who were admitted to the hospital. They found that when PCT testing was ordered, there was a median decrease in hospital length of stay from six to five days, and a median decrease in days of antibiotic therapy from nine to eight days. They also found that mortality decreased from 26.1% to 22.5% and readmission rates decreased from 26.1% to 22.5% (P<0.001 for all parameters).
As the understanding of how measuring PCT over time can provide insight into the progression of the infection, clinicians will feel more comfortable making patient care decisions based on these results, which will ultimately lead to better outcomes, the pharmacists said.