Procalcitonin-Guided Antibiotic Prescribing for Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the Emergency Department

Strengths

Strengths of this project include its multimodal implementation and overall pragmatic design, which reflects real-world utilization of procalcitonin by ED HCPs. The HCPs were not mandated to follow the procalcitonin algorithm, and the use of clinical judgment was strongly encouraged. This project occurred concomitantly with the VA Infectious Disease Academic Detailing education program. The program focused on clinician education for the proper diagnosis and treatment of respiratory tract infections. In addition, viral illness packs were introduced as part of this initiative to reduce unnecessary antibiotic prescribing. The viral illness pack included standard items for symptom relief, such as saline nasal spray, cough drops, and hand sanitizer, as well as an explanation card of why the patient was not receiving antibiotics. Several studies have suggested that patients expect a prescription for an antibiotic when they present with respiratory tract symptoms, and HCPs often are compelled to maintain patient satisfaction, thus leading to unnecessary antibiotic prescriptions.¹⁴ The viral illness pack helped fulfill the patient’s expectation to receive treatment after seeking care. In addition, the project lead was available full time during the first month of PCT algorithm implementation to address questions and concerns, which may have improved HCPs overall confidence in using PCT.

Limitations

Limitations of this project include its population and its retrospective nature. The PVAHCS patient population is predominantly older, more White, and more male compared with the general civilian population, and results may not be generalizable to other populations. Data were limited to documentation in the electronic health record. The population was based on data extraction by the ICD-10 code, which may not be an accurate capture of the total population as HCPs may not select the most accurate ICD-10 code on documentation. Another potential limitation was the COVID-19 pandemic which may have resulted in HCPs ordering PCT more frequently as more patients presented to the ED with undifferentiated respiratory symptoms. Finally, there were minimal differences observed in reexacerbation rates; however, although the sample size was powered to detect a difference in antibiotic prescriptions, the sample size was not powered to detect a statistically significant difference in the primary safety outcome.

Conclusions

PCT-guided antibiotic prescribing significantly reduced the number of antibiotic prescriptions without an observable increase in reexacerbation rates for patients with mild and moderate AECOPD in the ED. This study provides a pragmatic evaluation of PCT-guided antibiotic prescribing for patients with AECOPD solely in the outpatient setting. Acute phase reactants like PCT can play a role in the management of AECOPD to reduce unnecessary antibiotic prescriptions.