Improving Antibiotic Stewardship: Optimizing Procalcitonin Utilization in Patients Admitted with Respiratory Tract Infections

From the 2023 HVPA National Conference

Sunjay Letchuman BBA (Icahn School of Medicine at Mount Sinai) Ajani Gyasi BS, Alexander Zhou MS, Alicia Yang BS, Zach Gallate MS, Batsheva Weinberger BSN, Anthony Delicce MD, Reem Aoun MD, Anne Linker MD, Risa Fuller MD

Background:
The overuse of antibiotics leads to medication adverse events, Clostridioides difficile infections, antibiotic resistance, and lengthened hospital stay. Up to one-third of antibiotics prescribed for respiratory infections may be unnecessary or excessively long. Procalcitonin is a serum biomarker that can be used to help determine whether a respiratory infection has a bacterial or non-bacterial origin. Several hospital systems have successfully implemented an algorithm-based approach for using procalcitonin levels to safely reduce inappropriate antibiotic use. Past studies have found that procalcitonin levels below 0.1µg/L have a negative predictive value of 96.3% for bacterial infection, and antibiotics are strongly discouraged for those patients.

Objective:
To improve antibiotic stewardship, we aim to decrease antibiotic duration by 12 hours within one year in patients presenting to the emergency room with suspected respiratory infections with a procalcitonin level of less than 0.1µg/L.

Methods:
At the Mount Sinai Hospital, EPIC data from September 2021 to October 2022 was queried for all patients in which a procalcitonin test was indicated (i.e., suspected respiratory tract infections). Procalcitonin testing rates and antibiotic duration were analyzed in Python. The Institute for Healthcare Improvement’s “Model for Improvement” tool is being used to develop, test, and implement interventions, which include: 1) adopting a straightforward decision-making algorithm, 2) increasing appropriate procalcitonin collection on admission through electronic medical record modifications, and 3) increasing awareness through targeted educational campaigns (e.g., grand round presentations, resident noon conferences).

Results:
Analysis of admissions data revealed that patients with procalcitonin levels less than 0.1µg/L received antibiotics for 48 hours on average, while patients with procalcitonin levels greater than 0.5µg/L received antibiotics for 25 hours on average. In 36% of patients with respiratory tract infections, procalcitonin testing was not ordered. This suggests that procalcitonin results are not being appropriately utilized to aid in clinical decision making and that procalcitonin labs are being under-ordered. Interventions are currently being implemented, and post-intervention results will be ready to share in late 2023.

Conclusions:
At the Mount Sinai Hospital in New York City, utilization of procalcitonin testing for patients with respiratory tract infections is not fully aligned with best practice. In a third of indicated cases, procalcitonin may be under-ordered, and in other cases, the results of procalcitonin testing may not be optimally informing clinical decision making. Interventions aimed at ensuring antibiotic therapy is ended for patients with procalcitonin levels of less than 0.1µg/L have the potential to reduce unnecessary antibiotic usage and antibiotic resistance.

Clinical Implications:
Globally, inappropriate antibiotic use is costly for patients, hospitals, and the healthcare system. Streamlining the procalcitonin ordering pathway and promoting its proper use could improve antibiotic stewardship and patient outcomes.

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