Clinical Progress Note: Procalcitonin in the Management of Pediatric Lower Respiratory Tract Infection

Although PCT shows promise as a biomarker to reliably rule out bacterial infection, several potential limitations exist in assessing its role in pediatric LRTI. Atypical bacterial infections (ie, Mycoplasma pneumoniae) and localized bacterial infection may not induce significant PCT production, as has been shown in adults and children with tonsillitis, localized skin infections, endocarditis, or empyema (Table).¹² The majority of clinical trials in LRTI have been conducted in the adult population,⁴ with the number of pediatric trials remaining small.^2,3 Given the predominance of viral LRTI in children compared with adults, the utility of PCT may differ in these populations.^13,14 Furthermore, existing studies demonstrate mixed results regarding the magnitude of benefits that PCT may provide in terms of limiting antibiotic use. Another concern is the potential of PCT to increase unnecessary antibiotic use in those with viral LRTI,³ as PCT may also be increased in populations with systemic inflammation from nonbacterial causes.^12,15

The misuse of antibiotics is a public health crisis resulting in the emergence of antibiotic-resistant pathogens and adverse outcomes, including Clostridioides difficile infection, drug toxicities, and increased healthcare costs.¹⁶ Pneumonia is responsible for more days of antibiotics than any other disease in children’s hospitals and is an important target for stewardship efforts.¹⁷ PCT is a promising biomarker for distinguishing bacterial from viral infection, and its use may help in making informed antibiotic decisions and predicting disease outcomes in pediatric LRTI. Although PCT has been cleared by the FDA for assisting with antibiotic decisions in pediatric LRTI, the majority of evidence supporting this indication is drawn from adults. Additional studies are needed prior to the widespread implementation in the pediatric population, but the results of available pediatric studies show promise. The clinical context and severity of patient presentation are important when considering whether or not to use PCT and how to best interpret PCT levels when making clinical management decisions. The utility of PCT for antibiotic initiation in the pediatric population is encouraging given the predominance of viral etiologies in pediatric LRTI. Currently available data demonstrate the value of serial PCT measurements in antibiotic de-escalation and promoting antibiotic stewardship for children and adults.^2-4 As with all new diagnostic modalities, provider education is paramount to ensure a safe and value-driven implementation.

Disclosures

Dr. Katz received investigator-initiated grant funding from Roche and bioMérieux to conduct research involving procalcitonin in the past three years. Dr. Sartori has nothing to disclose. Dr. Williams received investigator-initiated grant funding from bioMérieux to conduct research involving procalcitonin in the past three years.

Funding

This work was supported by the National Institute of Health (1T32AI095202-07).

Disclaimer

This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, Roche, or bioMérieux.