1. Is the VIDAS B. R. A. H. M. S PCT assay able to detect a bacterial throat infection? Mr Ajith P George MBChB, MRCS, DO-HNS ENT SpR

2. Overview Aims & Objectives Background Methodology Further investigations

3. Aims 1- To establish whether the VIDAS BRAHMS PCT assay is sensitive enough to detect a proven bacterial infection of the throat 2- To establish whether PCT rises following routine tonsillectomy 3- To determine whether post tonsillectomy secondary haemorrhage (PTSH) is associated with a bacterial infection

4. Objectives To reduce routine unnecessary prescription of antibiotics in ENT. – Reduce Cost – Decrease incidence of allergic reactions – Decrease side effects of medication – Slow the progression of antibiotic resistance

5. Background Unnecessary antibiotic prescribing is leading to an increase in bacterial resistance 1 Procalcitonin in the management of LRTI’s has been demonstrated to – Reduce antibiotic prescribing 2 – Decrease antibiotic cost per patient 2 Patients admitted for PTSH to ENT units across the UK are routinely prescribed antibiotics There is no clear evidence to suggest PTSH is associated with a bacterial infection 3

6. What is Procalcitonin? 116 AA polypeptide pro-hormone of calcitonin Produced in c-cells Released from the liver during the acute phase response Bacterial specific marker of infection- Levels related to severity

7. Current applications of PCT Managing LRTI Acute exacerbation of COPD Differentiating viral and bacterial meningitis Pneumonia sepsis induced ARDS PUO Differentiating sterile and infective pancreatitis

8. Evidence for PCT benefit Christ-Cain et al compared PCT based therapeutic strategy against conventional management N=243, Single blinded cluster RCT (119 standard group and 124 PCT group)

9. Management Hx, examination, TPR, FBC, U&E’s, CXR, MC&S, ABG’s, Spirometry, Bronchoscopy

10. Outcomes of Christ-Cain et al P>0.05 – QOL – VAS – WCC – CRP – Admission – Hospital stay – Death – ITU P<0.05 – Antibiotic prescription – Duration of antibiotic prescription – Antibiotic cost per patient

11. Methodology Stage I – A cross sectional analysis to establish a mean PCT level for patients with a proven bacterial throat infection To determine whether the assay is sensitive enough Stage II – A case control study to determine whether a significant difference exists in mean PCT levels of post tonsillectomy patients (control) against patients with a bacterial throat infection To determine whether tonsillectomy causes a rise in PCT Stage III – A case control study to determine a significant difference in mean PCT levels of PTSH patients against post tonsillectomy patients (control) To establish whether PTSH is associated with a bacterial infection and therefore justifies antibiotic prescription

12. Further Investigations Do patients admitted with Glandular Fever Justify antibiotic prescription? Determining between viral and bacterial acute otitis media in children Differentiating bacterial or inflammatory causes of acute salivary gland disease Investigating the use of high sensitive PCT to determine if bipolar tonsillectomy is more traumatic than the cold steel technique.

13. Thank you!

14. References 1-Cars O, Hogberg L, Murray M et al. Meeting the challenge of: A concerted global response is needed to tackle rising rates of antibiotic resistance. Without it, we risk returning to the pre-antibiotic era warn Otto Cars and colleagues.BMJ 2008; 337: a1438. 2-Christ-Cain M, Jaccard-Stolx D, Bingisser R et al. Effect of Procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster- randomised single-blinded intervention trial. The Lancet 2004; 363: 600-607 3-George A, Coulson C, De R. Procalcitonin: A bacterial specific marker of infection. Clinical Otolaryngology 2007; 32(4):310.