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Paperchase 1: Procalcitonin

Andrew Buelt, DO and Joe Weatherly, DO
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Discuss findings from the recent article by Self, Wesley H., et al. "Procalcitonin as an early marker of the need for invasive respiratory or vasopressor support in adults with community-acquired pneumonia." Chest (2016).

 

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Seth E. -

Any thoughts on the ProREAL trial published in Arch Int Med (Arch Intern Med. 2012;172(9):715-722)? In contrast to ProRATA and PASS trial, this trial showed no difference in mortality and significant difference in number of days on antibiotics. It is the study that the ID doctors in my hospital system sited to support their use of procalcitonin in antibiotic stewardship.

Rob O., MD -

here is the reply from Joe W... I think the use of Procal is the problem, not the biomarker itself. Similar to other screening bio-markers or screening tests, it can be fraught with problems and is really only helpful when we understand the broad spectrum of things that can/will affect it. I think we use tests with worse sensitivity routinely. Using it like a D-dimer in patients that havent been screened correctly will send too many people to the CT scanner with normal findings and cause harmsWe are just used to using them and understand....well that is likely a stress reaction...well that is from steroids....well that is from a chronic condition. The fact that biomarkers dont change mgmnt at times begs the question...why did you order it...and what were you looking for? Then finding the correct test is the best idea IMO. But we have done more invasive and intense things with other screening tools. Like Stress tests leading to normal cath in patients without STEMI or NSTEMI. D-Dimer leading to CTA of normal lungs. I think this is why clinical suspicion trumps and at times is as bad as the biomarker, education and familiarity. bad biomarker vs experienced clinician at his best...Clinician wins. Great test/biomarker vs average physician... We have seen this is "under diagnosis" studies and bounce back rates in ER or PCP office. Over screening with mammogram and the harms that are done with it vs the mortality benefit from the testing. We havent ever used Procal universally and followed a guideline in its use. I am not sure it is ready for that.

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