A #MedTwitter🧵on the frequently obtained, but ever mysterious🕵️‍♀️ Procalcitonin (PCT) 🦠

💡 What is it?
💡 Where does it come from?
💡 What factors/comorbid conditions may impact PCT?

#IDTwitter #TwitteRx
1/n First, let’s discuss the normal, physiologic role of PCT 🧬

✨116 chain amino acid
✨Neuroendocrine hormone
✨Produced by thyroid C-cells
✨Enzymatically cleaved to calcitonin
✨ Regulate Ca+2 & PO4- homeostasis

DOI 10.1093/ajhp/zxaa089

@AJHPOfficial @SESmithPharmD Image
2/n Why/How does PCT ⤴️ in bacterial infections?

✨Nonendocrine tissues (adipocytes, spleen, pancreas, etc) produce PCT but LACK 🛑 enzymes to cleave to calcitonin

✨Stimulus for non-thyroid PCT production include
1️⃣LPS/bacterial toxins ⚠️
2️⃣Cytokines (IL6, TNFa, ILb) Image
Contrary to common belief, leukocytes only play a minor role in PCT production.

Below 👇🏻 shows a 🐁 study of tissue ⤴️ in CALC-1 gene expression in response to sepsis 🦠

doi.org/10.1210/jcem.8… Image
3/n Why PCT does not ⤴️ during viral 🦠 infections?

Viruses 🦠 stimulate production of INF-y

INF-y inhibits🛑CALC-1 gene expression thus PCT is not produced 💡 Image
4/n What are the kinetics of PCT in bacterial infections?

From time of bacteria exposure
⏰ PCT levels ⤴️ within 3-6 hrs
⏰ PCT peaks at 6 - 14 hrs
⏰ PCT half-life = 22 - 36 hrs

Approximately 30% of PCT is cleared via the kidneys

biomerieux-diagnostics.com/sites/clinic/f… Image
5/n What factors impact PCT levels?

⚠️ SEVERAL factors MAY impact PCT levels to varying degrees (surgery, AKI/CKD, malignancy, etc)

🔑 Assess PCT in the context of pt specific factors and other markers of infection

💡Highly recommend reading the article in tweet 1/n ImageImage
6/n How to use PCT in clinical practice? 👩🏻‍⚕️

Remains a 🔥 topic of continued research 🔬 but as it stands currently, PCT can be a useful tool to aid in the de-escalation of ABX/ assessing response to therapy💊

📝This should NOT be used ALONE to diagnose infection
Concluding thoughts 💭on PCT

✨PCT produced via nonendocrine tissues in response to bacterial infection
✨Useful to differentiate btwn bacterial vs viral inf 🦠
✨Impacted by various factors/conditions, thus not be used alone to 👀 for inf

🧵 inspired by @pouyeah

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More from @theABofPharmaC

21 Sep
Let’s talk CSF 🧠 💦

☝️ What is it & why is it important?
✌️ Key considerations in CSF sampling 🧪 & analysis 🧐 for suspected infection 🦠

A #NeuroTwitter 🧵 inspired by bedside rounds with attending @BuslKatharina & NCC team👏🏻
So to start, what is CSF? 🤔

CSF▶️clear, sterile fluid secreted by choroid plexus 💦 in the ventricles ➡️circulates throughout the subarachnoid space🧠 & spinal canal🦴

⭐️Function▶️ protective barrier 🛡 provides nutrients 🍎& facilitates removal toxins/metabolic byproducts⚠️
Now, let’s discuss🖐key pearls when analyzing CSF🧐for poss infection🦠

1️⃣Consider the source!

Obtained from a…
▶️“Closed”system, ie LP💉?
▶️“Open”system, ie EVD🧠?

⚠️Interpret CSF💦from “open”sys w/caution▶️blood🩸& inflammation🔥from underlying condition are often present
Read 8 tweets
20 Aug
Now that the salty🧂debate on the TYPE of fluid to use in the ICU has largely been solved, how about the RATE of IVF? 🤔

Back to the BaSICS💦

✅The Balanced Solutions in Intensive Care Study📖 (BaSICS) ▶️compared 333mL/hr vs 999 mL/h

Does IVF rate impact 90-day mortality? 🤔
💡 10, 520 ICU pts randomized 🏥

Fluid volume:

1162 mL in the SLOW infusion group 💦
vs. 1252 mL in the FASTer group

🛑NO difference in☝️ outcome: 90-day mortality (HR 1.03, CI, 0.96-1.11)

🛑No difference in✌️outcomes: RRT, AKI, ventilator free days, ICU/hospital LOS
Notably, when reviewing this study, the baseline characteristics are a key 🔑 consideration

< 5% of the cohort in both groups had sepsis (⬇️ the generalizability in this population) 🦠

Patients with AKI or ESRD were excluded from the trial 💡
Read 5 tweets
27 May
Alert 🎙Pharmacy Grand Rounds Thread Ahead! 🚨

Last week I had one of my final presentations of the year! With a catchy title😉

Urine for an Update! Updates in the management of metastatic urothelial cancer

Hold your bladders, this is an extensive update! 😂
#oncopharm Image
Bladder cancer can be divided into two ✌️subtypes:
1) Non-muscle invasive: encompasses in-situ and localized disease➡️5-yr OS >70%

2) Muscle invasive: encompasses regional or metastatic disease➡️5-yr OS dismal especially for metastatic disease 😔 Image
Cisplatin=SOC
50% of pts w are ineligible due to older age👵🏻, poor PS, ⬇️ renal function, ⬇️hearing, neuropathy, heart failure 🫀& other comorbities that ⬆️ risk of ⚠️

Carboplatin yields inferior responses➡️NOT 🙅🏻‍♀️ an equal alternative due to ⬇️ OS😢➡️pt left w/minimal tx options Image
Read 12 tweets
26 Apr
What medications 💊 are should be avoided 🛑 or used with caution ⚠️ in patients with Myasthenia Gravis? 🤔

See 👀 the thread 🧵below⤵️ that summarizes an amazing grand rounds presentation by @UKPharmRes PGY1 @AliW_PharmD on key 🔑 medication considerations in MG
1️⃣Antibiotics to avoid or use w/caution🦠 💊

🛑FQs = FDA BBW for ⤴️ risk of MG crisis ➡️ avoid use if possible
⚠️ Macrolides ⤴️ rate of MG crisis (case reports)
⚠️ AG linked to ⤴️ ICU acquired weakness & exacerbate ‼️ MG crisis
📝Risk⬆️ w/neomycin vs. tobramycin & amikacin
Antibiotics considered to be SAFE alternatives to the above include

✅Beta-lactams
✅Tetracyclines
✅Linezolid
✅Bactrim

Ex. In an MG patient who presents 🏥 w/CAP 🫁 ➡️ choose ceftriaxone + doxycycline✅ OVER ceftriaxone + azithromycin🛑
Read 7 tweets
12 Mar
Urine Trouble: A review of Immune checkpoint inhibitor associated nephritis

See below some of the data I collected on this topic from a recent inservice! @OncoPharmPod #nephrotwitter #oncopharm
Immune checkpoint inhibitors (ICI) ➡️revolutionized tx 💊 of various malignancies
✅Treatment that offers some pts🙋🏻‍♀️a chance of cure🤯

Also see a range of unique toxicities⚠️➡️autoimmune in nature

An emerging one of which is nephritis! (Insert a needed kidney emoji)
Pathogenesis of ICI-nephritis is unknown

Some hypothesis exist 🧐
✅stopping the breaks on the immune system results in excessive immune activation➡️ATIN
✅Previous renal insult or concurrent medications that lead to ATIN can accelerate the emergence of renal injury ☢️
Read 8 tweets
2 Sep 20
I would like to make a few points of clarification for yesterday tweet on Vasopressin for cardiogenic shock.

🔑 point: Vasopressin is not “preferred” nor 1st line in CS but “may be considered” in select cases

Please read further thread 👇🏻👇🏻
It should have stated “may consider” VP as the suggestion of benefit in the JAHA article on CS was based on theoretical benefit and a ☝️ post hoc analysis of the VASST trial which included septic shock patients, notably a VERY different pathophys than CS.
pubmed.ncbi.nlm.nih.gov/22518026/
Article did not also mention potential risk of harm from Vasopressin. (fluid retention, lack of inotropic activity, etc) and as @brentnreed pointed out, patients in this study required MORE inotropic support when vasopressin was used Image
Read 5 tweets

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