Biomarkers in the ICU: less is more? No
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LESS IS MORE IN INTENSIVE CARE
Biomarkers in the ICU: less is more? No Antoni Torres1,2* , Antoni Artigas3 and Ricard Ferrer4,5* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
In recent years, the use of biomarkers in the ICU has increased exponentially. Only a few of them are used in clinical practice. However, as any measurement that helps to make clinical decisions, these biomarkers have detractors and defenders. Due to space constrictions, we decided to give arguments in favor of using biomarkers only in two frequent medical conditions with high morbidity and mortality in ICU, such as pneumonia and sepsis.
Pneumonia Most of the information about biomarkers in pneumonia comes from procalcitonin (PCT), which is the most frequent biomarker currently used in clinical practice. PCT is an acute-phase reactant primarily produced by the liver in response to bacterial infections. Cytokines associated with viral infections attenuate PCT induction, but some elevation in its expression can occur in atypical pathogen pneumonia. Thus, patients with lower respiratory tract infections, including those with lung infiltrates, can often have antibiotics safely withheld when PCT levels are low, provided that clinical judgment supplements biomarker measurements. PCT levels may vary during illness, with higher levels in patients presenting within 3 days from symptoms onset [1]. In documented influenza cases, PCT levels do not have a sufficient positive predictive value to indicate a bacterial coinfection; however, they have a high negative predictive value and could help rule out bacterial coinfections. PCT measurements may be inaccurate in renal failure, which can falsely elevate PCT levels by interfering with their elimination. Moreover, some dialysis *Correspondence: [email protected]; [email protected] 1 Department of Pulmonology, Respiratory Institute, Hospital Clinic of Barcelona, Barcelona, Spain 4 Intensive Care Department, Vall D’Hebron University Hospital, Barcelona, Spain Full author information is available at the end of the article
membranes can remove PCT, which can lead to falsely low measurements (Figure 1). Taking into account all the considerations mentioned above, both PCT measurements and clinical judgment have to be included in the initial management of CAP, including severe CAP [2]. The second indication of PCT is the duration of antibiotic treatment. In the ProCAP study, serial measurements of PCT were used to guide treatment duration, which was 55% shorter with PCT guidance than in the control group, although the duration in the control group was longer than current standards (12 days vs. 5 days for the PCT group). A study of 1359 Emergency Department patients (68% with CAP) from six hospitals showed that PCT guidance reduced antibiotic treatment duration, use, and side effects compared to standard care [3]. Furthermore, a patient-level meta-analysis of 2910 patients showed that PCT guidance reduced antibiotic treatment duration to 5.7 days from 6.2 days in controls (p
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