Volume : 13, Issue : 04, April – 2026
Title:
PROCALCITONIN (PCT) STEWARDSHIP FOR RESOURCE-LIMITED INDIAN WARDS: A NARRATIVE REVIEW WITH AN IMPLEMENTATION PROTOCOL
Authors :
Supriya Kulkarni, Saba Mubeena, Swathi P, E. Sreeja, Dr. P. Soma Sekhar*
Abstract :
In India, antimicrobial resistance poses a significant challenge in hospitals where antibiotics are frequently overused or misused, particularly in resource-limited settings. Procalcitonin (PCT), a biomarker proven globally to identify genuine bacterial infections and guide antibiotic de-escalation, remains underutilised in Indian hospital wards — not due to lack of efficacy, but because of insufficient laboratory infrastructure, inadequate clinician training, and the absence of locally adapted protocols. This narrative review synthesises global evidence on PCT-guided antibiotic stewardship, contextualises it within the realities of Indian secondary and tertiary care settings, and proposes a novel PCT Stewardship Algorithm alongside a structured Implementation Protocol designed for resource-limited Indian wards.
The review examined PCT’s biological basis, mechanism of action, and established kinetics, followed by a critical appraisal of landmark global trials — including ProHOSP, ADAPT-Sepsis, and multiple Cochrane analyses — as well as Asia-Pacific and India-specific guidance. Current barriers to PCT adoption in Indian hospitals were systematically assessed, including laboratory gaps, physician knowledge deficits, patient population complexity, and the underdeveloped role of clinical pharmacists in stewardship activities.
The proposed PCT Stewardship Algorithm (Table 1) provides a colour-coded, stepwise framework with PCT-specific thresholds, clinical judgment checkpoints, and adjustments for special populations including patients with chronic kidney disease, tuberculosis, and immunocompromised states. The accompanying Implementation Protocol delineates laboratory infrastructure requirements, staff training pathways, audit and feedback mechanisms, and key performance indicators. If adopted, this model has the potential to reduce unnecessary antibiotic exposure by an estimated 1.5 to 2.5 days per patient, improve antimicrobial stewardship programme outcomes, and support India’s National Action Plan on Antimicrobial Resistance.
Keywords: Procalcitonin; antimicrobial stewardship; antibiotic de-escalation; resource-limited settings; India; antimicrobial resistance; implementation protocol; narrative review.
Cite This Article:
Please cite this article in press P. Soma Sekhar et al., Procalcitonin (PCT) Stewardship For Resource-Limited Indian Wards: A Narrative Review With An Implementation Protocol, Indo Am. J. P. Sci, 2026; 13(04).
REFERENCES:
1. Becker KL, Snider R, Nylen ES. Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations. Crit Care Med. 2008;36(3):941–952.
2. Bouadma L, Luyt CE, Tubach F, Cracco C, Alvarez A, Schwebel C, et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet. 2010;375(9713):463–474.
3. Chambliss AB, Patel K, Colon-Franco JM, Dasgupta A, Donato LJ, Grenache DG, et al. AACC Guidance Document on the Clinical Use of Procalcitonin. J Appl Lab Med. 2023;8(3):598–634.
4. Charani E, Tarrant C, Moorthy K, Sevdalis N, Brennan L, Holmes AH. Understanding antibiotic decision making in surgery: a qualitative analysis. Clin Microbiol Infect. 2019;25(1):91–99.
5. Dark P, Hughes D, Martin GP, Timm A, Carlson GL, Barber V, et al. ADAPT-Sepsis: Procalcitonin- or CRP-guided antibiotic treatment discontinuation compared to standard care for critically ill patients with sepsis. JAMA. 2024. doi:10.1001/jama.2024.26458.
6. Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;(2):CD003543.
7. Hessels LM, Speksnijder E, Paternotte N, Van Slobbe-Bijlsma ER, Coutinho JM, Wiersinga WJ, et al. Procalcitonin-guided antibiotic prescription in patients with COVID-19. Chest. 2023;164(3):596–605.
8. Hey J, Thompson-Leduc P, Kirson NY, Zimmer L, Wilkins D, Rice B, et al. Procalcitonin guidance in patients with lower respiratory tract infections: a systematic review and meta-analysis. Clin Chem Lab Med. 2018;56(8):1200–1209.
9. ICMR (Indian Council of Medical Research). Annual Report: AMR Surveillance Network. New Delhi: ICMR Department of Health Research; 2022.
10. Johnson SA, Rupp AB, Rupp KL, Reddy S. Clinical outcomes and costs associated with procalcitonin utilisation in hospitalised patients with pneumonia, heart failure, viral respiratory infection, or COPD. Intern Emerg Med. 2021;16(3):677–686.
11. Kiya GT, Asefa ET, Abebe G, Mekonnen Z. Procalcitonin-guided antibiotic stewardship: a narrative review. SAGE Open Med. 2024;12. doi:10.1177/11772719241298197.
12. Kotwani A, Wattal C, Katewa S, Joshi PC, Holloway K. Antibiotic use in the community: what factors influence primary care physicians to prescribe antibiotics in Delhi, India? Fam Pract. 2011;27(6):684–690.
13. Lee CC, Kwaa ALH, Apisarnthanarak A, Sirichotirat P, Lu MC, Liu JW, et al. Procalcitonin-guided antibiotic stewardship in Asia-Pacific countries: adaptation based on regional epidemiology. Clin Chem Lab Med. 2020;58(12):1983–1991.
14. Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, et al. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med. 2023;49(6):615–632.
15. Meier MA, Branche A, Neeser OL, Kellner T, Benz F, Urwyler SA, et al. Procalcitonin-guided antibiotic treatment in patients with positive blood cultures. Clin Infect Dis. 2011;53(11):1116–1123.
16. Ministry of Health and Family Welfare, India. National Action Plan on Antimicrobial Resistance (NAP-AMR) 2017–2021. New Delhi: Government of India; 2017.
17. Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–655.
18. Papp M, Kiss N, Baka M, Melicher D, Hornyak I, Berki T, et al. Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival: a systematic review and meta-analysis. Crit Care. 2023;27:394.
19. Pathak A, Mahadik K, Dhaneria SP, Sharma A, Bhartiy SS, Lundborg CS. Antibiotic prescribing in outpatients: hospital and seasonal variations in Ujjain, India. Scand J Infect Dis. 2011;43(6–7):479–488.
20. Reinhart K, Meisner M. Biomarkers in the critically ill patient: procalcitonin. Crit Care Clin. 2012;27(2):253–263.
21. Saigal S, Sharma SK, Khilnani GC, Hadda V, Singh TK, Wangdong T, et al. Guidelines for the rational use of procalcitonin in Indian clinical settings. Lung India. 2023;40(2):152–170.
22. Samsudin I, Vasikaran SD. Clinical utility and measurement of procalcitonin. Clin Biochemist Rev. 2019;38(2):59–68.
23. Schuetz P, Beishuizen A, Broyles M, Ferrer R, Gavazzi G, Gluck EH, et al. Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimised clinical use. Clin Chem Lab Med. 2019;57(9):1308–1318.
24. Schuetz P, Christ-Crain M, Thomann R, Falconnier C, Wolbers M, Widmer I, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomised controlled trial. JAMA. 2009;302(10):1059–1066.
25. Schuetz P, Müller B, Christ-Crain M, Stolz D, Tamm M, Bouadma L, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2012;(9):CD007498.
26. Simon L, Gauvin F, Amre DK, Saint-Louis P, Lacroix J. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis. 2004;39(2):206–217.
27. Surviving Sepsis Campaign. International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Med. 2021;47(11):1181–1247.
28. Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis. 2014;14(8):742–750.
29. Wacker C, Prkno A, Brunkhorst FM, Schlattmann P. Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(5):426–435.
30. WHO (World Health Organization). AWaRe (Access, Watch, Reserve) Classification of Antibiotics. Geneva: WHO; 2021.