The Value of Procalcitonin (PCT) in Critical Care Patient Management: Best Practice and HECON Findings in India

This is a verbatim transcript of an interview conducted with Dr Niraj Tyagi in December 2025. The transcript has been lightly edited for clarity.

Introduction

Hi, I’m Dr. Niraj Tyagi. I’m a consultant at the Institute of Critical Care Medicine, Sir Ganga Ram Hospital. I’ve been part of the ISCCM initiative that objectified Procalcitonin antibiotic guidance in our country. I am also part of HECON study, which is primarily a study about antimicrobial stewardship or sepsis and lower respiratory tract.

What are the key unmet needs in critical care patient management, particularly for sepsis patients?

So we all understand that initiation of empirical antibiotics, particularly in septic patients, is time critical. What is also clear is that if we choose these antibiotics inappropriately, which fail to cover the entire spectrum of organisms, it is going to lead to increased mortality. But there’s a flipside to it. The moment this coverage is there, what we need to recognise is that while C.difficile is most spoken about secondary infection, the recent literature highlights other issues. For example, this paper that we got from my country, from the state of Gujarat, from the city of Baroda, is to assess the impact of broad spectrum antibiotics on secondary fungal infection rates. And the implications were reaching double digits, almost 9.8%. That was the rate of secondary fungal infections in this particular paper.

Cut across the globe, ERS 2023 paper in critically ill patients showed that the ventilator associated pneumonia incidences increased as part of overall adverse clinical outcomes. The moment anti-aerobic antibiotics were always part of the empirical regime. So probably we physicians need to recognise that these are the challenges, while managing critically ill patients, and we need to recalibrate our strategies in light of these evidences.

How is the biomarker like Procalcitonin (PCT)  able to aid critical care, and how was it implemented in Sir Ganga Ram Hospital?

When we see the guidance that comes from ISCCM that I was part of, regarding use of rationalisation of antibiotic by using Procalcitonin as a biomarker, we realise that most of the time it has been able to bring down the treatment to less than seven days, except maybe in cases of non-fermenters or when suspecting gram positive infections. The trend of Procalcitonin and otherwise improving patients is important because it will give physicians convictions by bringing objectivity into the decision making tree. For example, in my own ICU, we are doing serial Procalcitonin and allow us to reduce the duration of antibiotics to around seven days in most of the patients.

If I talk about how we adopted the practice of integrating Procalcitonin about AMR and de-escalation decision tree in my hospital, so most of that time, we do it at day zero and when the patient is initiated on antibiotics, mostly at the 24 hours, to ensure that we know the peak. And then we repeat it on the day we are planning to de-escalate or stop the antibiotics. For example, if it’s a community acquired pneumonia, we will probably do it on day seven. And if it does come down below 0.5 or it is less than 80% of the peak, it gives me the courage to stop it straightaway in that patient who has improved. And I was likely to stop antibiotics on that particular day. So on and so forth. It applies to other situations in which I may need to continue antibiotics for probably a day or two more. So three serial Procalcitonin is what we are mostly practising and prescribing to our patients in Ganga Ram ICU.

Sometimes clinicians express concern about the cost of utilising biomarkers, for example, PCT. What are your thoughts on these concerns?

To me, the cost of Procalcitonin or any other biomarker should be looked at not in isolation but in connection with potential benefits it has to offer. For example, reduction in a single day of antibiotics. And if we are able to reduce this in a single day, probably it is going to offset whatever cost is being incurred in running serial Procalcitonin. For example, per sepsis case, the cost savings in India are to the tune of 18,000 rupees. And if we talk about lower respiratory tract infection, the cost benefit is coming to the tune of 15,000 rupees per LRTI case.

So combine this cost saving and reduce secondary infections that we’re going to achieve if we reduce the overall duration of antibiotics, less disturbance of gut microbiota, reduce frequency of adverse events, and a better financial matrix. So to me, it’s a clear win-win situation. In my institute, what we see is that in real life practice, we have been able to integrate it beautifully and even the multidisciplinary discussion that we have. Having this parameter in terms of objective and numbers is likely to yield to consensus when we are going to stop antibiotics. For example, now we are thinking of bringing down the antibiotics from seven days in most of the infections to probably five days, at least for community acquired pneumonias and infections, and urinary tract and all.

What are your top pieces of advice for clinicians across APAC looking to implement PCT in their critical care management?

When we talk about the APAC region, there are two things. The cost of healthcare admission is either borne by individuals after their pockets, or it’s the state that sponsors. In both situations, the argument can be made. For example, the HECON study drives the point home that we are able to reduce the cost of antibiotics even for a lower respiratory tract infection by almost 15,000 rupees. So if somebody is spending less number of days in the hospital, that is a benefit for the hospital management. It doesn’t matter whether the cost of this hospitalisation is coming from the patient’s pocket or the institution is bearing it.

The second thing is when we talk about the ICU beds, which are in general available for patients who need them, a reduced hospital stay or ICU stay, or somebody who is already admitted, is going to make them available for somebody who needs from the community or otherwise. So what we need to understand is that APAC has much more benefit to achieve by integrating Procalcitonin guidance to reduce the antibiotic burden as well as financial burden. It’s going to lead to improved AMR and stewardship practices.

The views and opinions expressed by Dr Niraj Tyagi are his own views and opinions. Roche disclaims all liability in relation to these views and opinions.