Infectious Diseases

ISSN: 2374-4235 (Print) 2374-4243 (Online) Journal homepage: https://www.tandfonline.com/loi/infd20

Review of clinical practice guidelines on the use of

procalcitonin in infections

Benita Tujula, Sari Hämäläinen, Hannu Kokki, Kari Pulkki & Merja Kokki

To cite this article: Benita Tujula, Sari Hämäläinen, Hannu Kokki, Kari Pulkki & Merja Kokki
(2019): Review of clinical practice guidelines on the use of procalcitonin in infections, Infectious
Diseases, DOI: 10.1080/23744235.2019.1704860

To link to this article: https://doi.org/10.1080/23744235.2019.1704860

Published online: 20 Dec 2019.

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INFECTIOUS DISEASES, https://doi.org/10.1080/23744235.2019.1704860
2019; VOL. 0,
NO. 0, 1–8

REVIEW ARTICLE

Review of clinical practice guidelines on the use of

procalcitonin in infections

Benita Tujulaa,b , Sari H€am€al€ainenc, Hannu Kokkib, Kari Pulkkid,e and Merja Kokkia,b
a
Department of Anaesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland; bSchool of Medicine, University of
Eastern Finland, Kuopio, Finland; cDepartment of Medicine, Kuopio University Hospital, Kuopio, Finland; dLaboratory Division,
Turku University Hospital, Turku, Finland; eDepartment of Clinical Chemistry, Faculty of Medicine, University of Turku,
Turku, Finland

ABSTRACT
Background: Procalcitonin is a biomarker that can be used to diagnose bacterial infection and monitor treatment. Clinical
practice guidelines are evidence-based recommendations by experts that aim to aid decision-making. In this systematic
review, we searched for clinical practice guidelines and evaluated recommendations given regarding use of procalcitonin.

Methods: Four biomedical databases (PubMed, Scopus, Cochrane Database and Web of Science) and various national med-
ical sites were searched for clinical practice guidelines. Guidelines that mentioned procalcitonin were included in
the review.

Results: Seventeen guidelines were included. The earliest were published in 2009 and the latest in 2018. A majority
(12/17) recommended use of procalcitonin or stated that it can be useful. One national guideline did not recommend pro-
calcitonin, stating that there is no need for any biomarkers in diagnostics of community-acquired pneumonia in adults.
Four guidelines stated no evidence to recommend or not recommend procalcitonin use. Thirteen of the guidelines com-
mented on other concomitant or alternate biomarkers, mainly C-reactive protein. Five guidelines suggested decision limits
for procalcitonin. None took a stand on how often procalcitonin should be analysed, and if it should be used as a single or
as multiple measurements.

Conclusions: One international and 11 national clinical practice guidelines endorse the use of procalcitonin in differential
diagnosis of bacterial infections and/or to monitor antibiotic therapy. However, the evidence for or against the use of pro-
calcitonin is weak.

KEYWORDS ARTICLE HISTORY CONTACT

Procalcitonin Received 6 September 2019 Merja Kokki
clinical practice guideline Revised 4 December 2019 merja.kokki@kuh.fi
C-reactive protein Accepted 9 December 2019 Department of Anaesthesia and Intensive
Care, Kuopio University Hospital, PO Box 100,
FI-70029 KYS, Kuopio, Finland

ß 2019 Society for Scandinavian Journal of Infectious Diseases

2 B. TUJULA ET AL.
Introduction
Procalcitonin (PCT) is a serum prohormone released
from various tissues after induction by proinflammatory
mediators and endotoxins. Clinically, PCT is most com-
monly measured in serum and is used as an indicator of
severe bacterial infection such as sepsis, bacterial menin-
gitis and pneumonia [1].
PCT has been used as a biomarker for severe infec-
tions for over 25 years [2]. However, there is no consen-
sus on the use of PCT in clinical practice. It seems
superior for diagnosis of bacterial infection compared to
the common biomarker C-reactive protein (CRP). Yet,
like other biomarkers, PCT has relatively low sensitivity
and specificity [3]. Traditionally, PCT has been used in
situations where differential diagnostics is needed.
Recent research has indicated that PCT is valuable when
monitoring antibiotic treatment, and that PCT can be
useful to reduce antibiotic use in several severe bacterial
infections [4,5]. PCT may be better used as a serial
(delta-PCT) than a single measurement [6].
Clinical practice guidelines (CPGs) are evidence-based
recommendations designed to aid in decision-making
regarding treatment, but adherence is not compulsory
[7]. To be adopted by physicians, CPGs should be devel-
oped by independent and unbiased committees of
experts, provide the best available evidence, be regularly
updated, and the process should be transparent [8].
To the best of our knowledge, there are no data on
how PCT is presented in CPGs and whether it is advo-
cated. Thus, we designed this systematic review to
evaluate if CPGs comment on the use of PCT and if so,
whether PCT use was recommended. The aim was to
assess (i) in which clinical context the use of PCT was
considered and (ii) if other biomarkers were recom-
mended and, if so, were they recommended dominantly,
concomitantly or secondary to PCT. The hypothesis of
this study was that only a limited number of guidelines
consider the use of PCT. We assumed that the guidelines
on sepsis were most likely to comment on the use of
PCT. It was not known if guidelines regarding other clin-
ical contexts could be identified, although PCT can be
used in various bacterial infections.
Material and methods
The CPGs regarding PCT were searched for in February
2019. A systematic search was performed to four bio-
medical literature databases without language restric-
tion. Additionally, 12 European national medical sites,
two American medical databases and three medical cites
from other countries were searched for guidelines
regarding PCT.
First, we searched PubMed with the search: (procalci-
tonin OR PCT) AND (infection OR sepsis OR septic) and
filters: Guideline, Consensus Development Conference,
NIH, Practice Guideline, Systematic Reviews, Meta-
Analysis. The PubMed search yielded 132 results, which
were limited by the researcher to 111 articles that had
the words guideline, meta-analysis or systematic review
in the title. After the initial limitation, the abstracts were
read and two were recorded as guidelines on the use of
PCT [9,10].
Second, a Scopus search was performed with the
search: (procalcitonin OR PCT) AND (infection OR sepsis
OR septic) AND (guideline) AND NOT INDEX (medline)
AND (LIMIT-TO (DOCTYPE, ‘re’)). This resulted in 566
articles, of which 44 included the words guideline, meta-
analysis or systematic review in the title. After browsing
the abstracts eight articles were recoded as guidelines
[11–18]. One guideline in Spanish was also found, but its
English version was archived by the publisher as it was
from 2006 and it was discarded from the current review.
Third, a Cochrane Database search was performed
with the search: (procalcitonin OR PCT) AND (infection
OR sepsis OR septic) with five results. Only one included
the words guideline, meta-analysis or systematic review
in the title, but had already been included to the
Scopus search.
Fourth, a Web of Science search was performed with
the search: (procalcitonin OR PCT) AND (infection OR
sepsis OR septic) AND (guideline) with 410 results. Out
of these articles, 27 included the words guideline, meta-
analysis or systematic review in the heading. After
browsing the abstracts no article was identified as an
additional guideline.
The National Guideline Clearinghouse (USA) was
searched with the search term ‘procalcitonin’. Five
guidelines were found, three of which included a recom-
mendation on PCT use [19–21].
The Infectious Diseases Society of America (IDSA) guide-
lines were searched with the search term ‘procalcitonin’
and three additional guidelines were found [22–24].
Last, several known European websites (K€ayp€a Hoito,
Finland; Socialstyrelsen, Sweden; Den Norske
Legeforening, Norway; Sundhedsstyrelsen, Denmark;
Embaetti landlaeknis, Iceland; Zorginstituut Nederland,
the Netherlands; The National Institute for Health and
Care Excellence (NICE), United Kingdom; The Scottish
Intercollegiate Guidelines Network (SIGN), Scotland;
Haute Autorite De Sante, France; Arbeitsgemeinschaft

der Wissenschaftlichen Medizinischen Fachgesellschaften
(AWMF), Germany; Ministero della Salute, Italy; Direç~ao
Geral da Sau de, Portugal) with medical guidelines, the
Malaysian Ministry of Health guidelines, the Australian
Clinical Practice Guidelines and the New Zealand
Guidelines Group were searched and guidelines, that
included recommendations regarding the use of PCT in
English or that had an English abstract, were included.
Two further guidelines were found but one was consid-
ered withdrawn by SIGN as it was over 10 years old.
Thus, only one additional guideline was included in the
review [25].
Results
Seventeen guidelines were included in this systematic
review (Table 1). The earliest guidelines were from 2009
[12,17] and the most recent from 2018 [11,16,17]. There
were 16 national guidelines and one international
CPG [19].
Six of the 17 guidelines considered patients with
pneumonia or other respiratory tract infections [10,12,
14,15,17,22], five patients with sepsis [9,11,18,19,25], two
patients with chronic obstructive pulmonary disease
(COPD) [16,21], two patients with cancer and neutro-
penia [11,13], one patients with meningococcal infection
[20], one patients treated in the intensive care unit (ICU)
[23] and one patients with central nervous system (CNS)
infections [24]. One CPG concerned only paediatric
patients [14].
Eight of the guidelines evaluated the use of PCT for
diagnosis [10–13,15,20,24,25], three for treatment moni-
toring [9,21,23] and six for both purposes [14,16–19,22].
Twelve guidelines recommended the use of PCT or
stated that PCT can possibly be useful [9,11,12,14,15,17,
18,20,22–25]. Four guidelines stated that there is a lack
of evidence for recommending PCT, or did not recom-
mend the use of PCT, or recommended against PCT use
[13,16,19,21]. One national guideline recommended
against using any biomarkers for initial evaluation of
community-acquired pneumonia (CAP) [10].
Out of the five guidelines on patients with pneumo-
nia, four recommended use of PCT [12,14,15,22], and
one was against any biomarkers in the initial evaluation
of CAP [10]. One advised against using PCT in CAP, but
stated, that PCT may be helpful in hospital-acquired
pneumonia (HAP) and ventilator-associated pneumonia
(VAP) [15]. One of the CPGs on pneumonia recom-
mended against using PCT for the decision of antibiotic
treatment initiation in patients with HAP or VAP but for
INFECTIOUS DISEASES 3
the use of PCT to monitor antibiotic treatment [22]. Four
out of five sepsis guidelines advocated the use of PCT
[9,11,18,25] whereas one stated that there is a lack of
evidence for routine use [19]. In two guidelines regard-
ing COPD, the use of PCT was not recom-
mended [16,21].
PCT use was recommended for decision about anti-
biotic discontinuation in five guidelines [9,17,18,22,23].
Twelve of the 17 guidelines did not comment on PCT
decision limits. One guideline suggested that PCT

1.5 ng/mL predicts development of septic shock in
febrile neutropenia [11]. One guideline found no need
for antimicrobial treatment in COPD exacerbation with
PCT <0.1 ng/mL [12]. One guideline commented on the
association between PCT >150ng/mL and high mortality
risk in paediatric patients with invasive meningococcal
disease (IMD) [20]. One guideline claimed that PCT
<0.5 ng/mL may help differentiate bacterial HAP/VAP
from non-infectious aetiologies and may guide in deci-
sions on antibiotic cessation [15]. One guideline stated
that systemic infection is unlikely when PCT <0.5 ng/mL,
probable when PCT
2ng/mL, and that PCT

2.99 ng/mL and clinical pulmonary infection score
(CPIS) enhances diagnostic accuracy for VAP [18].
Concomitant or alternate use of other biomarkers was
evaluated or mentioned in 13 guidelines [10–16,18–20,
22,24,25]. Three commented on the higher specificity of
PCT compared to CRP and other biomarkers [18,19,24].
In three guidelines, CRP was advocated as an alternative
to PCT [11,12,25] whereas in three, use of other bio-
markers than PCT was not recommended [14,15,22].
Two guidelines did not recommend any biomarkers
[10,13]. One guideline stated that CRP is the gold stand-
ard [16], and one mentioned that CRP can be used
instead of PCT but that PCT in serum rises earlier and
faster than CRP in IMD [20].
All but two guidelines defined the method of grading
evidence [10,19]. However, five that stated the method
of grading evidence did not grade the evidence and rec-
ommendation regarding PCT [11,13,16,17,21]. The most
popular method of grading evidence was Grading of
Recommendations Assessment, Development and
Evaluation (GRADE) scale used in six guidelines [9,18,
21–24].
Discussion
Contrary to the hypothesis, 17 guidelines were included
in the present review. Twelve out of 17 advocated the
use of PCT [9,11,12,14,15,17,18,20,22–25], of which two

Table 1. Guidelines.
Guideline
Cancer patients with
neutropenic sepsis [11]
International Guidelines for
Management of Sepsis and
Septic Shock [9]
PCT-testing for diagnosing and
monitoring sepsis [19]
Sepsis (adults) [25]
Prevention, diagnosis, treatment, DSG and DIVI
and follow-up of sepsis; first
revision of the S2k
guidelines [18]
Management of adults with HAP IDSA and ATS
and VAP [22]
Management of CAP in
adults [10]
Diagnosis and management of
CAP and HAP [15]
Diagnosis, prevention and
treatment of paediatric
VAP [14]
Patients with lower respiratory
tract infections and CAP [12]
Diagnosis and treatment of
COPD patients [16]
Management of COPD [21]
‘Rhinosinusitis’ –
Langfassung [17]
Healthcare-associated
ventriculitis and
meningitis [24]
Implementing an antibiotic
stewardship program [23]
Publishing institution
DGHO
Surviving Sepsis Campaign
NICE
Current Care Guideline
SADI
ICS and NCCP(I)
Working group of South Africa
Paul-Ehrlich-Society of
Chemotherapy, DGP, German
Infectious Diseases Society
and CAPNETZ
DGP, German Atemwegsliga
and ASP
NGC
DEGAM and DGHNOKHC
IDSA
IDSA and SHEA
4
Diagnostic or
Year Focus group Recommendation for the use of PCT Recommendation Grading treatment monitoring
2018 Sepsis 1.
1.5 ng/mL predictive for septic shock in Evidence not graded Diagnostics
febrile neutropenia Guideline graded
2016 Sepsis 1. Antibiotic cessation 1. and 2. Weak recommendation, Treatment monitoring
2. Cessation of empiric antibiotics when limited low quality of evidence
B. TUJULA ET AL.
clinical evidence of infection Guideline graded; GRADE
2015 Sepsis Insufficient evidence for routine clinical use Not stated Diagnostics and
treatment monitoring
2014 Sepsis 1. Sepsis diagnostics 1. Moderate evidence Diagnostics
2. Decreasing PCT in the first 3 days ! 2. Weak evidence
favourable prognosis Guideline graded
2010 Sepsis 1. PCT > CRP 1–4. Grade C, evidence IIb Diagnostics and
2. PCT <0.5 ng/mL systemic infection unlikely, Guideline graded; CEBM treatment monitoring

2 ng/mL probable and GRADE
3. PCT
2.99 ng/mL þ CPIS in VAP diagnostic
accuracy "
4. Antibiotic cessation
2016 Pneumonia 1. Antibiotic initiation: clinical 1. Strong recommendation, Diagnostics and
criteria > PCT þ clinical criteria moderate quality of evidence treatment monitoring
2. Antibiotic cessation: PCT þ clinical 2. Weak recommendation, low
criteria > clinical criteria quality of evidence
Guideline graded; GRADE
2015 Pneumonia Not recommended for initial evaluation Not stated Diagnostics
2012 Pneumonia 1. No need for routine use in CAP 1. Moderate evidence, strong Diagnostics
2. PCT <0.5 ng/ mL may help in HAP/VAP recommendation
diagnostics 2. Moderate evidence, weak
recommendation
Guideline graded
2009 Pneumonia 1. Diagnosis of VAP in children 1. and 2. Expert opinion, Diagnostics and
2. Treatment monitoring inconsistent or lacking evidence treatment monitoring
Guideline graded
2009 Lower respiratory 1. PCT <0.1 ng/mL in acute exacerbation of 1. B Diagnostics
tract infections COPD, antibiotic initiation not needed 2. A
and pneumonia 2. CAP: clinical criteria þ CRP or PCT Guideline graded; Oxford Centre
of Evidence-Based
Medicine grading
2018 COPD Insufficient evidence Evidence not graded Diagnostics and
Guideline graded treatment monitoring
2014 COPD Insufficient evidence for acute COPD Evidence not graded Treatment monitoring
exacerbations Guideline graded; GRADE
2018 Rhinosinusitis Can be used for initiation or cessation of Evidence not graded Diagnostics and
antibiotic treatment Guideline graded treatment monitoring
2017 Ventriculitis 1. Healthcare-associated bacterial ventriculitis 1. Weak recommendation, moderate Diagnostics
and meningitis and meningitis: CSF-PCT ± CSF-lactate evidence
2. Differential diagnosis: bacterial infection vs. 2. Weak recommendation, low
surgery vs. haemorrhage evidence
Guideline graded; GRADE
2016 ICU Antibiotic cessation in adult ICU patients with Weak recommendation, moderate- Treatment monitoring
suspected infection quality evidence
Guideline graded; GRADE
(continued)
 INFECTIOUS DISEASES 5

recommended use of PCT in one situation but not in

Evaluation, http://www.gradeworkinggroup.org/; HAP: hospital-acquired pneumonia; ICS: Indian Chest Society; ICU: intensive care unit; IDSA: Infectious Diseases Society of America; IMD: invasive meningococcal disease;
ur Allgemeinmedizin und Familienmedizin; DGHNOKHC: Deutschen
ur Pneumologie und Beatmungsmedizin; DIVI:
ASP: Austrian Society of Pneumology; ATS: American Thoracic Society; CAP: community-acquired pneumonia; CAPNETZ: Competence Network; CEBM: The Centre for Evidence-Based Medicine; COPD: chronic obstructive

NCCP(I): National College of Chest Physicians, India; NGC: National Guideline Clearinghouse; NICE: The National Institute for Health and Care Excellence; PCT: procalcitonin; SADI: Sociedad Argentina de Infectologı; SHEA:
ur Intensivund Notfallmedizin; DSG: Deutschen Sepsis-Gesellschaft e.V.; GCP: good clinical practice; GRADE: Grading of Recommendations Assessment, Development, and
treatment monitoring
another [15,22]. One CPG on CAP, published in 2015,
Diagnostic or

concluded that no biomarkers are of value in diagnostics

[10]. Four guidelines concluded that there is a lack of
evidence for recommendation for or against the use of
Diagnostics

Diagnostics
PCT [13,16,19,21], three of which were published in 2010
[13], 2014 [21] and 2015 [19]. The three most recent
CPGs were published in 2018, of which two recom-
3. Recommendation C, evidence III

mended use of PCT [11,17], while one CPG on COPD did

Recommendation Grading

not [10]. Research on optimal use of PCT has been

1. and 2. No evidence, GCP

Guideline graded; SIGN

active and, thus, more recent evidence might have had

ur Hals-Nasen-Ohren-Heilkunde, Kopf: und Hals Chirurgie e.V.; DGHO: German Society of Hematology and Medical Oncology; DGP: Deutsche Gesellschaft f€
Evidence not graded
Guideline graded

an impact on the conclusions.

None of the guidelines took a stand on how often
PCT should be measured and if it should be used as a
single or multiple measurement. Only five guidelines
suggested decision limits for interpretation of PCT
pulmonary disease; CPIS: Clinical Pulmonary Infection Score; CRP: C-reactive protein; CSF: cerebrospinal fluid; DEGAM: Deutsche Gesellschaft f€

[11,12,15,18,20]. The relation of kinetics, especially early

Insufficient evidence for initiation of antibiotics
origin and fever, or history of fever: either
2. Children with petechial rash of unknown

rise of PCT, to the timing of clinical decision may be

Recommendation for the use of PCT

variable and, thus, repeated measurements have been

PCT >150 ng/mL ! high mortality

Society for Healthcare Epidemiology of America; SIGN: Scottish Intercollegiate Guidelines Network; VAP: ventilator-associated pneumonia.
1. Early phase: PCT faster than CRP

advocated. Some data have indicated that PCT may be

3. Paediatric patients with IMD:

more useful when measured repeatedly [6].

In recent years, new evidence has emerged to sup-
in neutropenic cancer

port the use of PCT, especially regarding antibiotic treat-

ment [26,27]. These studies have shown that both ICU
PCT or CRP

patients and patients with various acute respiratory tract

infections benefit from PCT-based decision-making when
initiating and de-escalating antibiotic use as PCT guid-
ance is associated with decreased antibiotic use and
2010 Neutropenic cancer

lower mortality.
Focus group
2013 Meningococcal

Most PCT studies enrolled patients with sepsis, pneu-

infection

monia or patients in the ICU. These three patient popu-

lations compromised 11 of the 17 CPGs in this
systematic review. However, data indicate that PCT
Year

could be a feasible diagnostic aid in patients with sus-

pected severe infections of bacterial aetiology, such as
respiratory tract infections, abdominal infections like
Publishing institution

peritonitis, postoperative infections, meningitis, necrotiz-

ing fasciitis and neonatal infections [28–30].
In 2018, an international expert workshop constructed
a PCT algorithm for patients with sepsis and CAP [31].
Deutschen Interdisziplin€aren Vereinigung f€

Based on the Delphi method, the group concluded that,

IDSA
NGC

for optimal use, PCT should be evaluated together with

clinical assessment of the severity of illness and the
meningococcal disease [20]

probability of bacterial infection. They proposed that in

neutropenic patients with

patients with mild disease and low probability of bacter-

Management of invasive
Table 1. Continued.

Antimicrobial agents in

ial infection, a low PCT, <0.25 ng/mL in non-ICU patients

and <0.5 ng/mL in ICU patients should advise against
Gesellschaft f€
cancer [13]

the use of antibiotics. In patients with moderate or high

Guideline

severity of infection, empiric therapy may be used, but

can be discontinued if PCT declines from the peak by
6 B. TUJULA ET AL.
>80% and/or below the proposed cut-off values. They
proposed that PCT should be tested every 24–48 h to
monitor antibiotic treatment [31].
In 2017, the US Food and Drug Administration (FDA)
approved PCT for the guidance of antibiotic therapy in
lower respiratory tract infections and for discontinuation
of antibiotic treatment in patients with sepsis. In both
patient groups, PCT guidance is associated with lower
mortality. Lower respiratory tract infections include CAP,
acute bronchitis, and acute exacerbations of COPD [32].
Earlier in 2007, PCT was approved by the FDA for use in
combination with other laboratory findings and clinical
assessments in critically ill patients with suspected
severe sepsis and septic shock [33]. The FDA concluded
that sufficient clinical data indicate that PCT is a useful
biomarker when making decisions on initiation of anti-
biotic treatment in patients with suspected bacterial
infections. The FDA stated that appropriate use of PCT
could be useful as a tool to combat increased antimicro-
bial resistance since clinical data indicates that PCT-
guided management leads to fewer antibiotic initiations
and shorter courses of treatment. Patients may, further-
more, benefit by experiencing a decrease of one-fourth
in antibiotic-related adverse effects.
A guideline is only as good as the studies it is based
on, and therefore, grading studies are essential [34]. In
the present review, two guidelines did not report grad-
ing of the studies. As new data is emerging rapidly,
applying these data on guidelines is challenging and
may weaken adherence to guidelines. However, the ben-
efits of CPGs are recognized. Increased adherence to
guidelines has been associated with reduced mortality
[35] as patient care can be optimized and resources may
be assigned where needed.
In medicine, adherence and compliance are often
used synonymously with the degree to which patients
correctly follow medical advice. Adherence may be
described as doctors’ and patient’s willingness to follow
the recommended treatment, and compliance combines
willingness with ability to follow the recommendations.
However, poor adherence to clinical algorithms and
study protocols has been recognized as a factor that
may cause controversial results in studies concerning
PCT use for the discontinuation of antibiotic therapy. If a
study protocol is inadequately followed in one study
and adequately in another, the results may be contro-
versial [36,37].
It is unlikely that actual use of PCT correlates fully to
the guidelines. In Finland, the Current Care guideline
[25] suggests that PCT can be useful for diagnosis of
sepsis, but there is wide variation in PCT usage between
hospitals [38]. During 2015, one of Finland’s five tertiary
care hospitals did not use PCT at all, whereas another
performed over 5600 PCT measurements. Furthermore,
the purpose of PCT use, diagnostics or treatment moni-
toring, varied between hospitals [38]. However, it must
be noted that this Finnish guideline was published in
2014, and it is possible that clinical practices in Finland
were not fully adjusted to the guideline in 2015.
Adherence to institutionally-set local rules on PCT
guided antibiotic treatment was evaluated by Hohn and
colleagues. They noted that the PCT sampling protocol
was followed in less than 50% of patients, and that in
only one-third of patients, the recommended PCT sam-
pling and antibiotic discontinuation were performed
[39]. Low adherence to other CPGs in this context has
been observed. In the Surviving Sepsis Campaign com-
pliance to the guideline was only 36% [40].
The strength of this systematic review is the wide
search of databases and other sites. Nevertheless, it
must be noted that some guidelines regarding this sub-
ject may not have been found. The limitation of a CPG
review is that guidelines do not necessarily correspond
to actual clinical practice [38,41]. Moreover, PCT has limi-
tations as a biomarker for bacterial infection as it is
released in inflammatory responses to other causes.
However, when measured in severely ill patients with
suspected bacterial infections, needing differential diag-
nostics, PCT can be useful in decision-making.
Furthermore, PCT can aid antibiotic stewardship [26,27],
which is important as we face the threat of multidrug-
resistant bacteria.
In conclusion, 12 of the 17 CPGs endorse use of PCT
in differential diagnosis and/or in guidance of antibiotic
therapy. Four guidelines conclude that there is not
enough evidence to support recommendations for or
against PCT use. One national guideline did not recom-
mend use of any biomarkers for diagnosis of CAP. The
evidence on PCT in CPGs is of low to moderate quality,
and CPGs disagree on PCT use even when considering
identical clinical situations.
Disclosure statement
The authors have no conflicts of interest that are relevant to
this work.
Funding
This work was supported by Suomen Laboratoriol€a€aketieteen
Edist€amiss€a€atio
€, Helsinki, Finland.

ORCID
Benita Tujula http://orcid.org/0000-0001-6292-6923
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