Target Audience:

Who should attend:

• Clinical faculty from the University of Pittsburgh School of Pharmacy
• Clinical staff pharmacists employed by the University of Pittsburgh Medical Center and deployed throughout the hospital campus in unit based roles and centrally in the department of pharmacy's main pharmacy
• Student pharmacy interns currently working within the department of pharmacy
• Certified Pharmacy Technicians

Abstract
Respiratory infections occur frequently in both the inpatient and outpatient setting, and in many cases, antibiotics are empirically started due to an inability to designate between viral or bacterial causative pathogens. As a result, patients are often put on antibiotics for durations longer than needed due no resolution of illness as in many cases viral pathogens are the cause of illness. This trend in health care is harmful as it predisposes patients to unnecessary antibiotics and antibiotic associated adverse events (such as infection with Clostridioides difficile) and increases the risk of developing multi-drug resistant organisms.

In a hope of decreasing antibiotic exposure, biomarkers have been long sought after, with many studies examine C-reactive protein and estimated sedimentation rate. However, these biomarkers are nonspecific to bacterial infection and thus lack the ability to aid in antibiotic discontinuation. Procalcitonin on the other hand is a biomarker specific to bacterial infections, leading to much interest in its utilization and has gained FDA approval for its use in bacterial infections. However, many current guidelines do not recommend for its use in aiding in the initiation or the discontinuation of antibiotics currently. Though it must be noted that pivotal studies utilizing procalcitonin have been excluded in many cases in forming guideline-based recommendations, bring to question the true utility of procalcitonin based protocols from a guideline perspective.

Many of the studies conducted with procalcitonin have looked at examining efficacy of early discontinuation of antibiotics based on procalcitonin protocols through the lens of non-inferiority trials when compared to standard clinical practice. For many of these studies procalcitonin based protocols have been proven to be as safe as the standard of care which utilizes clinical signs and symptoms while also proving to lessening the incidence of antibiotic associated adverse events. These studies can be credited towards forming the basis for many of the proposed procalcitonin-based protocols that institutions have adopted, but currently procalcitonin has yet to be widely adopted throughout the United States given prior trials and a concern for overall utility.

Educational Objectives:

Upon successful completion of this continuing pharmacy education program, the participant should be able to:

• Define FDA based recommendations for procalcitonin levels in lower respiratory tract infections
• Discuss previous literature evaluating antibiotic management in procalcitonin-based protocols
• Recognize strengthens and limitations in procalcitonin-based antibiotic protocols for the management of lower respiratory tract infections

Pharmacy Continuing Education Credits In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. The assigned universal program number(s) is JA4008223-0000-23-114-H01-P.  This knowledge-based activity provides 1  contact hours of continuing pharmacy education credit. Disclaimer Statement:  The information presented at this activity represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses.

Suggested Additional Reading & Joint Accreditation Statement - Note: This Accreditation Statement Supersedes All Other Statements:

Suggested Additional Reading:

1. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67
2. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society [published correction appears in Clin Infect Dis. 2017 Nov 29;65(12):2161]. Clin Infect Dis. 2016;63(5):e61-e111
3. Schuetz P, Beishuizen A, Broyles M, et al. Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimized clinical use. Clin Chem Lab Med. 2019;57(9):1308-1318
4. Vaughn VM, Gandhi TN, Petty LA, et al. Empiric Antibacterial Therapy and Community-onset Bacterial Coinfection in Patients Hospitalized With Coronavirus Disease 2019 (COVID-19): A Multi-hospital Cohort Study. Clin Infect Dis. 2021;72(10):e533-e541
5. Davies J, Davies D. Origins and evolution of antibiotic resistance. Microbiol Mol Biol Rev. 2010;74(3):417-433.
6. Blasi F, Stolz D, Piffer F. Biomarkers in lower respiratory tract infections. Pulm Pharmacol Ther. 2010;23(6):501-507. doi:10.1016/j.pupt.2010.04.007
7. Hopstaken RM, Muris JW, Knottnerus JA,  et al. Contributions of symptoms, signs, erythrocyte sedimentation rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection. Br J Gen Pract. 2003;53(490):358-364
8. Hamade B, Huang DT. Procalcitonin: Where Are We Now? Crit Care Clin. 2020;36(1):23-40
9. Gilbert DN. Procalcitonin as a biomarker in respiratory tract infection. Clin Infect Dis. 2011;52 Suppl 4:S346-S350
10. Goldberg B. Clinical Considerations for Procalcitonin-Guide Evaluation and Management of Lower Respiratory Tract Infections and Sepsis. November 10, 2016. Accessed March 1, 2022. https://www.fda.gov/media/101233/download
11. Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059-1066

Joint Accreditation Statement:
In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Pharmacy (CPE)
This knowledge-based activity provides 1.0 contact hours of continuing pharmacy education credit.

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.