Clinical Investigations

Reliability of Admission Procalcitonin Testing for Capturing Bacteremia Across the Sepsis Spectrum: Real-World Utilization and Performance Characteristics, 65 U.S. Hospitals, 2008–2017*

Lawandi, Alexander MD, MS^1,2,3; Oshiro, Marissa MD, MS^1,3,4,5; Warner, Sarah MPH^1,3; Diao, Guoqing PhD⁶; Strich, Jeffrey R. MD^1,3; Babiker, Ahmed MBBS^7,8; Rhee, Chanu MD, MPH^9,10; Klompas, Michael MD, MPH^9,10; Danner, Robert L. MD^1,3; Kadri, Sameer S. MD, MS^1,3

Author Information

¹ Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD.

² Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.

³ Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD.

⁴ Division of Internal Medicine, Department of Medicine, Medstar Georgetown University Hospital, Washington, DC.

⁵ School of Medicine, Georgetown University, Washington, DC.

⁶ Department of Biostatistics and Bioinformatics, George Washington University, Washington, DC.

⁷ Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA.

⁸ Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA.

⁹ Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA.

¹⁰ Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA.

The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the National Institutes of Health.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

This research was supported (in part) by the Intramural Research Program of the National Institutes of Health, Clinical Center.

Drs. Lawandi, Warner, Strich, Danner, and Kadri received support for article research from the National Institutes of Health.

Drs. Lawandi, Warner, Strich, Danner, and Kadri disclosed government work. Dr. Rhee received funding from UpToDate and Cytovale. Dr. Klompas’ institution received funding from the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality; he received funding from UpToDate. Dr. Kadri received funding from the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Drs. Lawandi and Oshiro contributed equally to the article and are co-first authors.

*See also p. 1607.

For information regarding this article, E-mail: [email protected]

Critical Care Medicine 51(11):p 1527-1537, November 2023. | DOI: 10.1097/CCM.0000000000005968

Abstract

OBJECTIVES:

Serum procalcitonin is often ordered at admission for patients with suspected sepsis and bloodstream infections (BSIs), although its performance characteristics in this setting remain contested. This study aimed to evaluate use patterns and performance characteristics of procalcitonin-on-admission in patients with suspected BSI, with or without sepsis.

DESIGN:

Retrospective cohort study.

SETTING:

Cerner HealthFacts Database (2008–2017).

PATIENTS:

Adult inpatients (≥ 18 yr) who had blood cultures and procalcitonin drawn within 24 hours of admission.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Testing frequency of procalcitonin was determined. Sensitivity of procalcitonin-on-admission for detecting BSI due to different pathogens was calculated. Area under the receiver operating characteristic curve (AUC) was calculated to assess discrimination by procalcitonin-on-admission for BSI in patients with and without fever/hypothermia, ICU admission and sepsis defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. AUCs were compared using Wald test and p values were adjusted for multiple comparisons. At 65 procalcitonin-reporting hospitals, 74,958 of 739,130 patients (10.1%) who had admission blood cultures also had admission procalcitonin testing. Most patients (83%) who had admission day procalcitonin testing did not have a repeat procalcitonin test. Median procalcitonin varied considerably by pathogen, BSI source, and acute illness severity. At a greater than or equal to 0.5 ng/mL cutoff, sensitivity for BSI detection was 68.2% overall, ranging between 58.0% for enterococcal BSI without sepsis and 96.4% for pneumococcal sepsis. Procalcitonin-on-admission displayed moderate discrimination at best for overall BSI (AUC, 0.73; 95% CI, 0.72–0.73) and showed no additional utility in key subgroups. Empiric antibiotic use proportions were not different between blood culture sampled patients with a positive procalcitonin (39.7%) and negative procalcitonin (38.4%) at admission.

CONCLUSIONS:

At 65 study hospitals, procalcitonin-on-admission demonstrated poor sensitivity in ruling out BSI, moderate-to-poor discrimination for both bacteremic sepsis and occult BSI and did not appear to meaningfully alter empiric antibiotic usage. Diagnostic stewardship of procalcitonin-on-admission and risk assessment of admission procalcitonin-guided clinical decisions is warranted.

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Reliability of Admission Procalcitonin Testing for Capturing Bacteremia Across the Sepsis Spectrum: Real-World Utilization and Performance Characteristics, 65 U.S. Hospitals, 2008–2017*