● Procalcitonin's greatest use is to guide early antibiotic discontinuation

in patients with community-acquired pneumonia (CAP) based on defined

procalcitonin thresholds.
● In hospitalized patients with known or suspected CAP, procalcitonin levels can
help determine when to discontinue antibiotic therapy in immunocompetent
patients.
● Procalcitonin is not typically used to inform antibiotic initiation in
patients with known or suspected CAP.
● Empiric antibiotic therapy should never be delayed in critically ill patients.
● Certain infections require prolonged duration of antibiotics regardless of
procalcitonin levels, such as CAP complicated by Staphylococcus aureus
bacteremia.
● The American Thoracic Society (ATS) and Infectious Diseases Society of
America (IDSA) guidelines do not recommend procalcitonin to guide initiation
or withholding of antibiotic therapy for patients with CAP, but suggest that
serial procalcitonin measurement may be most useful in settings where the
average length of stay for patients with CAP exceeds five to seven days to
assess responsiveness to antibiotic choice.
● Antibiotics are generally discontinued in patients with procalcitonin levels that
are persistently <0.25 ng/mL, patients with procalcitonin levels <0.25 ng/mL
with probable viral CAP or a noninfectious syndrome, and patients with known
or suspected bacterial CAP who have received at least five days of
appropriate antibiotic therapy and have a procalcitonin level <0.25 ng/mL (or a
≥80 percent drop from peak level).
● Antibiotic therapy is generally continued in patients with known or suspected
bacterial CAP with procalcitonin levels that are declining but still ≥0.25 ng/mL.
● Procalcitonin is less certain for guiding antibiotic therapy in patients with
ventilator-associated pneumonia (VAP). We typically start antibiotics when the
diagnosis is suspected, regardless of the procalcitonin level.
● The use of procalcitonin to guide antibiotic therapy in patients with acute
exacerbation of chronic obstructive pulmonary disease (AECOPD) is
controversial.
● What happens when procalcitonin is used to initiate antibiotics:

Some trials showed reduced antibiotic exposure by 30 percent without

increasing adverse events while other studies showed higher short-term
mortality.

● The promise of procalcitonin lies in guiding antibiotic discontinuation

rather than initiation in patients with COPD.