Determine Clinical Utility For Procalcitonin-Myassignmenthelp.Com

Question: Discuss About The Determine Clinical Utility For Procalcitonin? Answer: Introduction The reflective journal report is based on the article, Procalcitonin-guided diagnosis and antibiotic stewardship revisited (1). The article is the narrative review on the potential of the infection biomarker procalcitonin in infections other than the respiratory tract infections and sepsis. The aim of the article is to determine the clinical utility for procalcitonin or PCT in other infections such as Urinary tract infections, meningitis, and other superficial infections. The use of antibiotic treatment can be challenging for physicians due to ambiguity in using the conventional diagnostic markers such as C reactive protein and blood cultures in-patient suspected to have infection. The limitation pertains to the sensitivity and specificity (2). Antibiotic treatment for prolonged period has adverse consequences. In fifty per cent of the cases, the antimicrobial use has been found inappropriate and is unneeded in inpatient setting (3). It may lead to the antibiotic resistance and colla teral damage such asClostridiumdiffiicile-associated diarrhea. Recently, there is an increasing focus on the Procalcitonin, as an infection marker. Under normal circumstances it is produced by the thyroid C cells. However, in the case of bacterial infections, PCT is produced by many body tissues and it parallels to the severity of the inflammatory insult. Further, it is the prognostic indicator that the higher serum level of PCT is associated with the risk of mortality (2, 4). There is a growing body of literature on the use of PCT for the rationale use of the antibiotics. Thus, strong scientific evidence is needed to diagnose the bacteria infection using this marker, so that the antibiotic treatment can be reduced in duration when compared to other standard care. Thus, it is important to determine the efficacy of the PCT guided therapy. The benefits may include quick diagnosis, reduced hospital stay of patients even in severe sepsis and mortality (1, 3). If the clinical evidence is strong, the clinicians will be benefited. They can quickly diagnose the bacterial infections and treat on time, to prevent the clinical outcomes. The aim of the reflective journal is to summarise the selected journal article and critically evaluate the content of the research paper. Lastly, the overall summary is discussed based on the critically appraisal. Summary of article In the article by (1), the author has intended to update the clinicians on the new indications for PCT after the review published in 2011 indicating the use of prolactin in diagnosis and treatment of the lower respiratory tract infections and sepsis. This author of the article has performed a narrative review of the studies published in the period 2012-2013. The review includes various observational and interventional research and study designs. Most of the study designs selected were randomised control trials (RCT), RCT with real life (registry), meta-analysis of the RCTs, observational RCT of secondary analysis, only observational metaanalysis study, and only observational study. These chosen studies have investigated the use of the PCT in different types of infections and at different sites. The rationale for this narrative review is the inappropriate use of the antibiotics. With the emerging bacterial infections and antimicrobial resistance, there is an urgent call for intense ef forts to deal with the self-limiting nonbacterial and resolving diseases (5). There is a need of the one size fits all approach. This narrative review by (1) may add to the growing body of literature, highlighting a useful strategy for antibiotics treatment reduction. In the given article, pulmonary site, the infections covered are AECOPD, Asthma, bronchitis, community acquired immunity, and pulmonary fibrosis and upper respiratory infections. The infections related to heart studied are congestive heart failure, and endocarditis. The infections related to abdominal region covered are pancreatitis, appendicitis abdominal infections with peritonitis, and urinary tract infections. The blood related infections that are considered for determining the efficacy of PCT are Blood stream infection, Neutropenia and Severe sepsis/ shock. Some studies are included in the narrative review and deal with other infections such as arthritis, erysipelas, meningitis, and postoperative infections. Lastly, the article draws conclusion based on the results from different studies (1). Critical evaluation of the article The strength of the narrative paper is the flexibility of narratives (7). The author has focused on the broad picture of the Procalcitonin-guided diagnosis. The article has presented a comprehensive background on the chosen research area and the related gaps in this domain (1). The article contains wide range of relevant information on the Procalcitonin-guided diagnosis and its potential as infection biomarker. The strength of the study is the comprehensive details on the limitations of PCT (6). The interpretation of role of PCT is made carefully. The drawback of PCT related to suboptimal sensitivity and specificity was necessary to get idea of its clinical implication (1, 2). The literature review could have been presented in the article (1) precisely, instead of directly starting with the review (8). The article grabs the readers attention as it had clear question and focused on range of infections. The review has specified the type of the studies considered that makes easy for the readers to comprehend the methodology. It is the advantage of the study (9). However, the narrative review is limited due to lack of presentation of the search strategy, inclusion and exclusion criteria. Thus, it remains ambiguous if the researcher had personal contact with the experts (8, 10). It is not clear if all the relevant studies in the chosen time frame were considered or not. The quality of the studies chosen for narrative review does not seem to be assessed and there is no hint on the assessment of the methodological quality. This is the drawback of the study. Hence, the validity of the narrative review is doubtful although the findings address the clinical question to some extent (11). It is evident from the paper (1) that the PCT is promising in reducing the antibiotic exposure. Thus, it will be highly beneficial for the patients suffering from the critically ill sepsis, UTIs, acute heart failure, meningitis, postoperative infections and other infections. If the antibiotics treatment can be reduced with PCT, it is added an advantage (12). Highlighting this aspect is the strength of the article. The most interesting finding was the antibiotic stewardship (for respiratory infection and sepsis) by monitoring PCT kinetics. It resulted in the shorter antibiotic treatment duration in case of other infections (2). The emphasis on the PCT kinetics for antibiotic stewardship for severe infections appeared to be the effective strategy to decrease the mortality due to short duration of the antibiotic treatment by early cessation of therapy. Highlighting these findings has positive clinical implications (1). This proves to be of prognostic value related to disease severity (1 2). The results are overall combined in a systemic manner, including all the studies selected. Different infections and the role of PCT in diagnosis and treatment are well presented under individual subheadings (13). The heterogeneity of the results are however, not considered by the author (14). The reviewer does not mention the other parameters related to the PCT evaluation such as odd ratio, relative risk, or p-value. It is not clear, if it was not mentioned or if it is not applicable to this review. Thus, the presentation of the results is descriptive. The tabular representation of the PCT cut off is mentioned among other parameters (15). The strength of the results section comes from the various settings that are useful for PCT-guided therapy. The theme of recoding the PCT values on admission can be of great help to the clinicians as it was found to reduce the antibiotic treatment in low risk situation (2, 3). The author at the end of the review emphasise on the need of the comparis on between CRP and PCT in terms of the antibiotic stewardship. The review concludes with need of intense efforts to reduce the inappropriate use of the antibiotics as also mentioned in other articles in this research area (1). These additional factors can be useful and be applied as it might contribute to the change in the clinical practice. There are several limitations to the narrative review inspite of the background of the broad topic. The nature of this type of research paradigm becomes too subjective in regards to the type of studies to be included or excluded and the overall conclusion drawn (16). The selection bias may lead to misleading results. The author has not conducted the systemic review for each type of the infection in the concerned article. Only selected studies based on the PubMed search were found and some were based on the authors expertise, that makes the results of the paper very enthusiastic due to subjective weighing of the studies chosen (1). Further, there is a probability of bias, as most of the studies did not bind the patient. When large set of studies are involved, it is challenging to determine and integrate the complex interactions (17). The author of the article has presented a very less data on the CRP markers of infection. Even for the other types of infections, PCT has not been well studied. This is the weakness of the study. However, there is a significant evaluation of the PCT marker and its role in different types of infection. The results related to this have been promising inspite of the limitations. The author of the chosen article has restricted the research to a very short time period that is 2012-2016. This is the drawback as the article has chance of missing relevant data pertaining to the research topic that has been published before this time (13). It may limit the reliability of the study and the conclusions dawn (15). Overall, the results are based on the personal evaluation, beliefs, thoughts and interpretations of the author. Since, it is an expert opinion; it can be considered an evidence of lowest type. These studies are not as rigorous as they should be (16). Systematic approach may eliminate the limitation of the narrative review. Thus, the futures studies may take this rigorous approach. This approach is suggested as systematic review is the reproducible and explicit summary of the health care interventions and their effects. Further, systematic review involves two reviewers and follows a well-structured peer review protocol. Since the reviewers review the methodology, the bias is reduced. The systematic review indentifies the quality of the chosen study therefore; they are more transparent than the narrative review. Further, systematic review is considered the cornerstone of the evidence based practice as it focuses on clinical question and indentifies the best evidence (18). The narrative question has established by developing a broad question. It should start with more clear and focused question. The focused question can include the population, intervention, comparison and outcomes. It is also called as PICO question in short and is effective in finding answers more efficiently. This process decreases the element of vague and chance of getting unnecessary results (19). Summary and discussion Based on the critical appraisal of the narrative review on the Procalcitonin-guided diagnosis, and antibiotics stewardship it is evident that there is a need of finding solution that will work as all purpose strategy. There is an emerging bacterial resistance to the antibiotics. However, the prolonged use of bacteria has many adverse consequences such as collateral damage and diarrhea associated with C.difficle. Earlier, many studies have tried to determine the efficacy of the PCT in the diagnosis and treatment of the bacterial infection. However, the focus of these previous studies was mainly on respiratory tract infections and sepsis. The narrative review however highlights the clinical utility for PCT in other infections such as Urinary tract infections, meningitis, and other superficial infections. This deviation in focus was necessary for the clinicians struggling with the prolonged use of the antibiotic therapy. Based on the findings of the narrative review, there are many clinical situations where the PCT may be useful. It includes the differentiation of the bacterial and the viral respiratory tract infection. PCT will be useful in the diagnosis of the septic arthritis, renal involvement in the paediatric urinary tract infections and distinguish between the bacterial and the viral meningitis. Other clinical situation were PCT can be used include monitoring of the response to the antibacterial therapy and diagnosis of the postoperative infection (systemic secondary infection) or cases of trauma, burns ad transplants (2, 3, 5). According to (4), clinicians should not make the decisions regarding the antimicrobial therapy based on the serum level of PCT. Rather; it will be effective if PCT is placed in the clinical context of each patient scenario (1, 4). The clinicians must consider the site of possible infection, the extent of bacteria invasion and the degree of illness. Other clinical data must also be considered, pertaining to the situation. However, once the use of PCT is approved, the factors to be considered are cost. It is expensive than CRP but hold greater value for determining the cessation of antibiotics. If there is a decreased antibiotic use, the cost savings through the use of the PCT can be identified. Based on the emerging studies, it can be concluded that, PCT appears to be persuasive and is an evidence based approach to use antibiotics more rationally. This article is like an eye-opener for diagnosis of different infections using PCT. There is a need of further research to compare the effectiveness of the CRP and PCT for diagnosis of adult emergency department patients. References Sager R, Kutz A, Mueller B, Schuetz P. Procalcitonin-guided diagnosis and antibiotic stewardship revisited. BMC medicine. 2017 Jan 24;15(1):15. Schuetz P, Daniels LB, Kulkarni P, Anker SD, Mueller B. Procalcitonin: A new biomarker for the cardiologist. International journal of cardiology. 2016 Nov 15;223:390-7. Sager, R., Wirz, Y., Amin, D., Amin, A., Hausfater, P., Huber, A., Haubitz, S., Kutz, A., Mueller, B. and Schuetz, P., 2017. Are admission procalcitonin levels universal mortality predictors across different medical emergency patient populations? 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