Case Study

Hemodialysis, Bacterial Pneumonia and Antibiotic De-escalation

Michael R. Broyles, PharmD – Director of Pharmacy and Lab Services

Age, sex:

83-year-old male

Chief complaint:

Bilateral rales and crackles in base of lungs, no shortness of breath, temperature: 37.7˚C, recent increased volume removed during dialysis to achieve goal weight

Significant medical history:

Chronic renal failure on hemodialysis three times a week, history of peritoneal dialysis for five years, autoimmune disease, hypertension (HTN), diabetes mellitus (DM)

Admission diagnostics:

Chest X-ray = pulmonary edema, heart normal size

Admission labs:

PCT = 2.47 μg/L, NT-proBNP = within normal limits, serum creatinine = 8.2 mg/dL, blood urea nitrogen (BUN) = 30 mg/dL, white blood count = 13.1 x 103/µL, neutrophils 82.1 x 109/L, lactate 2.2 mmol/L

Admitting diagnosis: Bacterial pneumonia

Treatment, interventions: Antibiotics started

Trend:

  • On admission: PCT = 2.47 μg/L
  • Day 1: PCT = 1.39 μg/L (decrease ~50% after dialysis)
  • Day 2: PCT = 0.97 μg/L (decrease ~30% no dialysis)
  • Day 3: PCT = 0.48 μg/L (decrease ~50% after dialysis)
  • Day 4: PCT = 0.41 μg/L

 

Resolution: Antibiotics discontinued on day four after two consecutive PCT measurements below 0.5. 

Key takeaways

 

Approximately 30% of PCT clearance occurs renally.1 The elevated PCT level on admission was consistent with bacterial pneumonia. The patient was successfully treated with antibiotics. Note: The difference in PCT decrease was higher on dialysis days (approximately 50%) vs. non-dialysis days (approximately 30%). This is to be expected— when there is renal impairment, PCT will only decrease by approximately 30%.1

 

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References
  1. Meisner M. Procalcitonin-biochemistry and clinical diagnosis. Dresden (Germany): UNI-MED-Verlag; 2010.