Should I order serum procalcitonin on my patient with suspected infection?

Two things to ask before you order procalcitonin (PCT): 1. Will it impact patient management?; and 2. If so, will the result be available in a timely manner ie, within hours not days?

Whatever the result, PCT should always be interpreted in the context of the patient’s illness and other objective data. Not surprisingly then, as a “screening” test, PCT may be more useful in patients with low pre-test likelihood of having bacterial infection, not dissimilar to the use of D-dimer in patients with low pre-test probability of pulmonary embolism1.  

Several potential clinical uses of this biomarker have emerged in recent years,  including:1,2

  • Helping decide when to initiate antibiotics in patients with upper acute respiratory tract infections and bronchitis. A normal or low PCT supports viral infection.
  • Helping decide when to discontinue antibiotics (ie, when PCT normalizes) in community-acquired or ventilator-associated pneumonia.
  • Helping monitor patient progress with an expected drop in PCT of about 50% per day (half-life ~ 24 hrs) with effective therapy.

Few caveats…

  • PCT may be unremarkable in about a third of patients with bacteremia (especially due to less virulent bacteria, including many gram-positives)3.  
  • PCT levels are lowered by high-flux membrane hemodialysis, so check a baseline level before, not after, hemodialysis4.
  • Lastly, despite its higher specificity for bacterial infections compared to other biomarkers such as C-reactive protein, PCT may be elevated in a variety of non-infectious conditions, including pancreatitis, burns, pulmonary edema or aspiration, mesenteric infarction (ischemic bowel), cardiogenic shock, and hypotension during surgery2.

 

References:

  1. Schuetz P, Muller B, Chirst-Crain M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections (review). Evid-Based Child Health (A Cochrane Review Journal) 2013;8:4;1297-137. http://onlinelibrary.wiley.com/doi/10.1002/ebch.1927/pdf
  2. Gilbert GN. Use of plasma procalcitonin levels as an adjunct to clinical microbiology. J Clin Microbiol 2010;48:2325-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897488/pdf/0655-10.pdf
  3. Yan ST, Sun LC, Jia HB. Procalcitonin levels in bloodstream infections caused by different sources and species of bacteria. Am J Emerg Med 2017;35:779-83. https://www.ncbi.nlm.nih.gov/m/pubmed/27979420/#fft
  4. Grace E, Turner RM. Use of procalcitonin in patients with various degrees of chronic kidney disease including renal replacement therapy. Clin Infect Dis 2014;59:1761-7. https://www.ncbi.nlm.nih.gov/pubmed/25228701
Should I order serum procalcitonin on my patient with suspected infection?

Should I routinely consider the possibility of pulmonary embolism (PE) in my patients hospitalized for syncope?

Syncope is a well-known initial manifestation of pulmonary embolism (PE)1.  However, given the varied causes of syncope, determining the prevalence of PE among patients hospitalized for syncope is important.   

A multicenter prospective study2 enrolled 560 patients not already on anticoagulation who were hospitalized for a first episode syncope.  Of patients who had either a high pretest probability for PE, positive D-dimer assay or both, PE was diagnosed in 17%, or nearly 1 of 6 of enrolled patients, based on CT or ventilation/perfusion scan. PE was found more frequently among patients with syncope of undetermined cause than those with an alternative explanation (25.4% vs 12.7%). 

Another multicenter prospective study (2019), however, found a much lower prevalence of PE (0.6%) among patients evaluated in the ED for syncope, including those who were not hospitalized.3 A related commentary on the article reported a prevalence of 4.1% in the total study population, assuming a “worst-case scenario calculation.” 4 

Given these divergent results, perhaps the best advice is to consider PE as cause of syncope in the proper context and minimize over testing when suspicion remains low.

 

References 

  1. Thames MD, Alpert JS, Dalen JE. Syncope in patients with pulmonary embolism. JAMA 1977;238:2509-2511. https://www.ncbi.nlm.nih.gov/pubmed/578884
  2. Prandoni P, Lensing AWA, Prins MH, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med 2016;375:1524-31. http://www.nejm.org/doi/full/10.1056/NEJMoa1602172
  3. Thiruganasambandamoorthy V, Sivilotti MLA, Rowe BH, et al. Prevalence of pulmonary embolism among emergency department patients with syncope: a multicenter prospective cohort study [published online January 25, 2019]. Ann Emerg Med. doi:10.106/j.annemergmed.2018. https://www.annemergmed.com/article/S0196-0644(18)31535-X/fulltext
  4. Anonymous. Pulmonary embolism uncommon in syncope hospitalizations. Pulmonology Advisor. February 6, 2019.  https://www.pulmonologyadvisor.com/pulmonary-embolism-uncommon-in-syncope-hospitalizations/printarticle/832069/

 

Contributed in part by Rebecca Berger  MD, Department of Medicine, Mass General Hospital, Boston, MA

If you liked this post, sign up under MENU and receive future pearls straight into your mailbox!

Should I routinely consider the possibility of pulmonary embolism (PE) in my patients hospitalized for syncope?