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HealthManagement, Volume 20 - Issue 5, 2020 Table of Contents - Volume 20 -

(/c/healthmanagement/issue/117057) Issue 5, 2020
Editorial

The Role of Procalcitonin for Risk

COVID-19 Superheroes
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Assessment and Treatment of COVID- Management Matters

19 Patients
Philipp Schuetz Conception of COVID-19 Auxiliary Hospital
(/viewProfile/9715/Philipp_Schuetz) from Nursing Management Perspective
(/c/healthmanagement/issuearticle/117064)
******@***gmail.c
om Fighting the Pandemic in Brazil - Experience
 Download Article (/pdf/article-download/the-role-of-procalcitonin-for-risk-assessmen
of Largest Hospital Network
Medical Share Back (/c/healthmanagement/issue/117057)
(/c/healthmanagement/issuearticle/117070)
University
Department - Procalcitonin is widely used to assess the risk of bacterial infection and disease progression. Point-of-View
Kantonsspital
Can it be an additional tool to identify COVID-19 patients at risk of severe disease? Agfa HealthCare Introduces XERO Universal
Aarau
Viewer & Microsoft Teams Integration
Switzerland
During COVID-19
Key Points (/c/healthmanagement/issuearticle/117071)
HealthManagement
The Role of Procalcitonin for Risk
MENU Procalcitonin (PCT) is a widely used biomarker to assess the risk of bacterial infection and
Assessment and Treatment of COVID-19
disease progression. Patients
About (/s/about-
3) Early evidence suggests that PCT may also be a valuable tool in identifying COVID-19 patients (/c/healthmanagement/issuearticle/117074)
at high risk for clinical deterioration or patients at risk for bacterial co-infection.
Team (/s/team) COVID-19 Antibody Testing – Why it
PCT helps to discriminate between milder cases and more severe cases. PCT also helps to Matters and Factors to Consider
Contact distinguish between severe bacterial pneumonia and mild viral pneumonia. (/c/healthmanagement/issuearticle/117077)
(/s/contact-1)
If a patient has bacterial co-infection, his prognosis and his mortality risk increases if early Imaging Solutions for a New Reality
Advertising antibiotic treatment is not initiated. (/c/healthmanagement/issuearticle/117080)
(/advertising)
Recent clinical findings show that unnecessary antibiotic use can be safely reduced in patients
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with low likelihood of bacterial co-infection indicated by low PCT values.
(/s/guidelines- Tragedy of COVID-19
for-submission- (/c/healthmanagement/issuearticle/117072)
of-articles-and- Nurses Are Not Soldiers
guest-blog- COVID-19 and Procalcitonin (/c/healthmanagement/issuearticle/117073)
posts)
Procalcitonin (PCT) is a widely used biomarker to assess the risk of bacterial infection and disease Radiographers on the Frontline
Author Guide progression. In patients with bacterial sepsis, suspected or confirmed lower respiratory tract (/c/healthmanagement/issuearticle/117075)
(/s/author-guide-
infections, including community-acquired pneumonia, acute bronchitis and acute exacerbations of “Not in My Care Home”
1)
COPD, PCT can be a useful decision-making tool for antibiotic therapy (Schuetz et al. 2018). In (/c/healthmanagement/issuearticle/117076)
Disclaimer
addition, early evidence suggests that PCT may also be a valuable tool in identifying COVID-19 Burning Platform for Change: COVID-19
(/s/disclaimer)
patients who may be at risk for bacterial co-infection. Experience in Ghana
Privacy Policy (/c/healthmanagement/issuearticle/117078)
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COVID-19 is a respiratory and systemic disease that has infected millions of people worldwide. Most Traversing the Unknown Frontlines -
policy)
patients experience a mild form of the disease but there is a certain percentage of patients who COVID-19 from a Resource Limited East
Cookie Policy progress to a very severe disease state that requires intensive care and invasive ventilation. In order to African Setting
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ensure better patient management and improved outcomes, early identification of patients who may
Terms and be at a higher risk of severe infection can play an important role. So Not Your Regular Flu
conditions (/c/healthmanagement/issuearticle/117081)
(/s/terms-and-
COVID-19 is a relatively new disease, and there is still a lot we don’t know about it. While we still need Superheroes: Behind the Scenes of COVID-
conditions)
more reliable data, evolving evidence suggests that the use of PCT can help physicians better 19
Copyright and (/c/healthmanagement/issuearticle/117082)
manage patients with COVID-19. We already know that in all the types of infections from the lung
permissions
(/s/copyright- such as bacterial pneumonia or other types of viral pneumonia, PCT helps to discriminate between We Salute Our Healthcare Heroes!
and-permissions) milder cases and more severe cases. PCT also helps to discriminate between severe bacterial (/c/healthmanagement/issuearticle/117086)

pneumonia and mild viral pneumonia. Battle to be Won by Virtue

(/c/healthmanagement/issuearticle/117087)
Most COVID-19 patients have very low PCT levels (<0.25µg/L or even <0.1µg/L) at the time of Healthcare Warriors of India
admission, but elevated markers of inflammation such as white blood count (WBC) and C-reactive (/c/healthmanagement/issuearticle/117088)
protein (CRP) indicate that they have inflammation in the lung. However, at a certain point, in the Fighting the Supervillain with Everyone’s
course of the disease, their PCT levels start to increase. This could be due to two reasons. One of Superpowers
them would be that the patient has acquired bacterial co-infection. This is common in patients with a (/c/healthmanagement/issuearticle/117089)
viral infection because once the lung tissue gets damaged by the virus, it’s easier for normal bacterial
Point-of-View
flora to gain access and become invasive. This results in the development of secondary bacterial
Through Crisis to Better Healthcare
pneumonia in these patients, which is typically confirmed through blood cultures, sputum tests and (/c/healthmanagement/issuearticle/117083)

Helping to Get Spain’s Largest COVID-19

radiological confirmation. If these tools show signs of bacterial pneumonia, it’s very important to start Treatment Center Up And Running
antibiotic treatment in these patients. If a patient has bacterial co-infection, his prognosis and (/c/healthmanagement/issuearticle/117084)

mortality risk increases if early antibiotic treatment is not initiated Crossing the Rubicon to a Digitally Enabled
Medical Care
(/c/healthmanagement/issuearticle/117085)
The other reason could be that a patient starts to deteriorate, his general condition becomes much
worse, he goes into shock and develops an inflammatory syndrome – a COVID associated
Winning Practices
pneumonitis, which has a complex pathophysiology with endothelial dysfunction. During this severe Remote Work and Virtual Consultations:
inflammation and septic illness, there is also translocation of bacteria through the gut membranes and Emergency Setup
a very strong induction of different cytokines. This increases PCT production by bacterial (/c/healthmanagement/issuearticle/117090)

translocation through the intestines but also directly because of the huge inflammatory boost and Telemedicine in Time of COVID-19
toxic syndrome that is developing in these patients. (/c/healthmanagement/issuearticle/117091)

COVID-19 Challenges of IT Team

Overall, if a patient has milder COVID-19 infection, they generally are expected to have low PCT (/c/healthmanagement/issuearticle/117092)
levels. This also confirms that it is not a bacterial infection but a viral infection. However, if, during the Digital Health After COVID-19 -
course of the disease, the patient gets worse, and his PCT levels increase, it must be taken seriously. #medicosfrentealcovid Experience
This does not necessarily mean that there is bacterial co-infection. That could be a possibility, but it (/c/healthmanagement/issuearticle/117093)
could also mean that the patient is going into severe inflammatory pneumonitis syndrome. In such
cases, treatment strategies such as corticosteroids may be considered. However, PCT in these
patients can function as a marker to monitor the patient and provide feedback on what’s going on in
the body of these patients. If a patient comes in with mild disease and low fever, PCT levels are
expected to be low. In patients who self-quarantined at home and did not come to the hospital, and if
their condition gets worse, PCT can be a useful prognostic marker as information about PCT levels
can give clinicians the confidence that the disease is not at a very severe stage. On the other hand, if
PCT levels are high, this could be an indicator that the patient’s condition has become severe either
because of a co-infection or because of inflammation.

Determining Bacterial Co-Infection: PCT and Other Biomarkers

There are two possibilities when determining co-infection. One would be to look at the host, i.e. the
(https://vip.healthmanagement.org/delivery/ck.php?
patient, and the second would be to look at the pathogens. PCT is a host driven marker. If PCT goes
oaparams=2__bannerid=958__zoneid=1__source=%
up, it is a strong indicator that the host has a problem. PCT is a much more potent tool compared to
other inflammatory markers such as CRP or white blood count because these are inflammatory
markers and are already increased in most of these patients due to inflammation.

PCT is a better marker because it’s much more specific towards bacterial infection. However, high
PCT levels alone do not prove there is co-infection. Once there is a patient with high PCT, there is still
a need to look at pathogen derived markers such as PCR, sputum culture etc. This can help prove
what type of infection it is because there could be different types of bacteria causing the problem.

The effectiveness of PCT as a prognostic tool for lung infection and for respiratory tract infections has
already been proven in several studies. There is also strong indication of its benefits in COVID-19
patients, but since this is a new disease, the evidence is still evolving. While we may not have strong (https://vip.healthmanagement.org/delivery/ck.php?
data at the moment, more studies show that PCT has significant prognostic implications (Gregoriano oaparams=2__bannerid=959__zoneid=7__source=%
et al. 2020), and it can help detect co-infection. Based on the Wuhan cohort, and also some data from
Italy and the U.S., the recommendation is to look at D-dimer levels to determine endothelial COVID-19 News (/covid-
dysfunction and vascular problems. However, PCT is being used in addition to other prognostic tools, 19)
for the purpose of monitoring patients and as an infection marker. So You Think You Got Microchipped? Prove
It!
(/s/so-you-think-you-got-microchipped-
PCT and Antibiotic Treatment prove-it)
People around the world are getting the
Evolving data show that more than 70% of COVID-19 patients get antibiotic treatment as it can be a COVID-19 vaccine. There are... Read more
challenge to identify COVID-19 patients without bacterial co-infection in whom antibiotics could be (/s/so-you-think-you-got-microchipped-
stopped safely. However, recent clinical findings prove-it)

(https://www.medrxiv.org/content/10.1101/2020.06.29.20136572v1)show that procalcitonin can help An Epiphany from Inside the COVID-19
Crisis in the UK
in the assessment of these patients and reduce unnecessary antibiotic usage (Williams et al. 2020)
(/s/an-epiphany-from-inside-the-covid-19-
(Figure 1).
crisis-in-the-uk)
The Lockdown May End, But Nursing Will
Continue My dear readers it is... Read more
(/s/an-epiphany-from-inside-the-covid-19-
crisis-in-the-uk)
Once a bacterial co-infection is established in a COVID-19 patient, PCT is very helpful to also monitor
Healthcare 4.6
the patient and guide treatment duration. Typically, if there is a patient with high PCT levels and if co-
(/s/healthcare-4-6)
infection is confirmed, it is important to bring PCT levels down by about 50% every other day. If the I am delighted to be taking over the editorial
levels do not drop, it would suggest that the treatment is not working. Hence, PCT is a very useful helm at HealthManagement.org... Read
marker. If PCT levels drop, it would indicate that the treatment is working and that the patient is on more (/s/healthcare-4-6)
track. Once the levels have dropped substantially – around 80 to 90% of the peak level - it is safe to
stop antibiotic treatment. This way, PCT is also a great tool to guide antibiotic treatment and can help
reduce the unnecessary usage of antibiotics. PCT is an excellent marker that gives clinicians
feedback on the course of the disease and how well treatment is working.

PCT is routinely used in our treatment setting, and we have evidence that PCT has strong prognostic
implications. While Switzerland did not have thousands of patients as in other countries, but still in the
patients that we treat, we use PCT, and we have clinical evidence that it is an effective tool for COVID-
19 patients (Gregoriano et al. 2020).

COVID-19 is a healthcare challenge that has shaken most healthcare systems around the world.
(https://vip.healthmanagement.org/delivery/ck.php?
When it first started in China, other countries underestimated the severity of the disease and the oaparams=2__bannerid=956__zoneid=8__source=%
implications of this infection. Now we know that this virus is causing very high severity of disease and
significant morbidity and mortality. We also know a little bit more about treatments and have a better
idea as to how to diagnose patients and how to treat them. Prevention by social measures is now the
main focus with different countries having different preventive measures in place. It is hoped that we
will continue to see a drop in cases, and this pandemic will pass. Things remain uncertain as to how
the next month will be with COVID-19 and whether we will continue to see cases in the coming
months or whether we will be able to get the situation under control globally. Only time will tell, but for
now, we can continue to do our best and diagnose, treat and manage COVID-19 patients to the best
of our ability.

Obviously, the COVID-19 infection is far too heterogeneous and complex to be reduced to a single
cut-off of any biomarker. Still, current evidence suggests that the likelihood for an adverse course with (https://vip.healthmanagement.org/delivery/ck.php?
pneumonitis and/or bacterial co-infection increases with increasing serum levels of PCT. Know- ledge oaparams=2__bannerid=930__zoneid=28__source=
of assay characteristics, particularly the functional assay sensitivity, and strengths, pitfalls and optimal
cut off ranges in a predefined clinical settings are prerequisites for its optimal use in clinical routine. JOIN OUR MANAGEMENT
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repeated measurements should always be performed in the inhospital setting. In addition, immuno-
modulating drugs may suppress the upregulation of different biomarkers including CRP, and increase Sign Up
levels of WBC. PCT seems to be less affected by steroid use, but again more research is needed to
better understand how different treatments for COVID-19 may influence PCT levels.

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References: 1 2 3 4 5 6

7 8 9 10 11 12 13
Gregoriano C et al. (2020) Characteristics, predictors and outcomes among 99 patients hospitalised
with COVID-19 in a tertiary care centre in Switzerland: an observational analysis. Swiss Med Wkly, 14 15 16 17 18 19 20
150:w20316. doi: 10.4414/smw.2020.20316
21 22 23 24 25 26 27

Schuetz P et al. (2018) Procalcitonin-guided antibiotic therapy algorithms for different types of acute
28 29 30
respiratory infections based on previous trials, Expert Review of Anti-infective Therapy, 16:7, 555-564,
doi.org/10.1080/14787210.2018.1496331

Williams EJ et al. (2020) Routine measurement of serum procalcitonin allows antibiotics to be safely
withheld in patients admitted to hospital with SARS-CoV-2 infection. medRxiv.
doi.org/10.1101/2020.06.29.20136572

 procalcitonin (/tag/procalcitonin), Brahms PCT

(/tag/Brahms%2520PCT%2520), COVID-19 (/tag/COVID-
19), bacterial coinfection (/tag/bacterial%2520coinfection)

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