From the 2018 HVPAA National Conference
Stanley Podlasek (Johns Hopkins Department of Pathology), Mark Landrum (Howard County General Hospital), Christina Mancini-Flegel (Johns Hopkins Hospital), Rupinder Sarai (Johns Hopkins Hospital), Swetha Paluru (Johns Hopkins Department of Pathology), Al Valentine (Johns Hopkins Department of Pathology), Jeanette Nazarian (Johns Hopkins Community Physicians), Robert Linton (Johns Hopkins Department of Emergency Medicine), Mindy Kantsiper (Johns Hopkins Internal Medicine), Karen Carroll (Johns Hopkins Department of Pathology)
Procalcitonin is a phase reactant prohormone with faster kinetics than C-reactive protein, and is thought useful in distinguishing bacterial infection from viral infection or other causes of inflammation. We introduced an FDA approved procalcionin assay at our 267 bed community hospital using the core lab automated chemistry platform, Cobas 6000.
Determine whether to introduce this assay into our hospital system.
We used procalcitonin as an adjunct in determining whether to initiate or discontinue antibiotic treatment in patients with ambiguous clinical findings for pneumonia or other possible bacterial infections. The infectious disease service initiated educational efforts on the appropriate use of the assay before it was introduced on site. We also invited chairs of emergency medicine, intensive care units, and hospitalists to join with infectious disease in the educational effort and to help maintain appropriate use of the test. The laboratory director reviewed orders for appropriateness. We considered appropriate test use to be for a patient on antibiotics with the additional condition that before ordering the assay and in consideration of other clinical data, such as fever, WBC count and imaging results, the ordering physician was willing to stop antibiotics if procalcitonin was less than 0.10 ng/mL.
By bringing this assay on site from our reference laboratory, Quest Diagnositics, the turnaround time was reduced from 24-36 hours to less than 1 hour. The cost was reduced from $163.64 to $23.00 per assay, and the number of orders increased from 1/day to 5/day (241/49 days). Based on this application of the test, we found by chart review of 237 patients (4 duplicate orders) that antibiotics were discontinued in 49 patients (average length of stay 3 days), not started in 25 patients (average length of stay 3 days), started in 7 patients, and delayed in 1 patient for two days. None of the 49 whose antibiotics were stopped, and none of the 25 whose antibiotics were not started had a positive culture. None of the 74 restarted antibiotics. This test was introduced during the peak of flu season, and was highly efficient in de-escalating antibiotics in patients with suspected coinfection with bacterial pneumonia. Conservative prediction of annualized cost savings is $551,224/year based on discontinuation or avoidance of antibiotics assuming $1000/patient-day and a one patient-day reduction in hospital stay ($200/day antibiotic cost + $800/day ICU hospital bed). Decreased laboratory expense is $17,753/year.
We consider the avoidance of unnecessary antibiotic administration useful in antibiotic stewardship, and we have become proponents for introduction of this test throughout our hospital system. Reduced hospital stay for antibiotic administration and monitoring, reduced or eliminated cost of antibiotics, and avoidance of potential side effects, add value to our medical care.
Implications for the Patient
- Procalcitonin is a high value laboratory assay.
- Procalcitonin assay contributes to antibiotic stewardship.
- Moving procalcitonin to the core chemistry platform greatly enhances its usefulness by at least one additional hospital/antibiotic patient-day avoidance.