Article

Clinical Outcomes Associated With Procalcitonin Algorithms to Guide Antibiotic Therapy in Respiratory Tract Infections

Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 02/2013; 309(7):717-8. DOI: 10.1001/jama.2013.697
Source: PubMed

ABSTRACT

Clinical question:
In patients with respiratory tract infection, is measurement of procalcitonin to guide antibiotic prescriptions associated with reduced antibiotic exposure without increases in all-cause mortality or treatment failure?

Bottom line:
The measurement of procalcitonin to guide initiation and duration of antibiotic treatment in patients with respiratory tract infections of varying severity is associated with lower antibiotic exposure without increasing all-cause mortality or treatment failure.

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Available from: Beat Müller, Jan 18, 2014
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    • "Thus, the results of this study suggest that, in a subject with low levels of PCT, the duration of antibiotic treatment might safely be reduced to 3 days. Even if a properly designed and powered study is required for corroboration before a specific recommendation can be made, our results are consistent with the efficacy and safety of the PCT-guided antibiotic treatment plan recently suggested in two important articles, i.e., a Cochrane review [32] and an authoritative synopsis of clinical evidence [23]. Our study has several limitations. "
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    ABSTRACT: The duration of antibiotic treatment of exacerbations of COPD (ECOPD) is controversial. Serum procalcitonin (PCT) is a biomarker of bacterial infection used to identify the cause of ECOPD. We investigated whether a PCT-guided plan would allow a shorter duration of antibiotic treatment in patients with severe ECOPD. For this multicenter, randomized, non-inferiority trial, we enrolled 184 patients hospitalized with ECOPD from 18 hospitals in Italy. Patients were assigned to receive antibiotics for 10 days (standard group) or for either 3 or 10 days (PCT group). The primary outcome was the rate of ECOPD at 6 months. Having planned to recruit 400 patients, we randomized only 183: 93 in the PCT group and 90 in the standard group. Thus, the completed study was underpowered. The ECOPD rate at 6 months between PCT-guided and standard antibiotic treatment was not significant (% difference, 4.04; 90% confidence interval [CI], -7.23 to 15.31), but the CI included the non-inferiority margin of 15. In the PCT-guided group, about 50% of patients were treated for 3 days, and there was no difference in primary or secondary outcomes compared to patients treated for 10 days. Although the primary and secondary clinical outcomes were no different for patients treated for 3 or 10 days in the PCT group, the conclusion that antibiotics can be safely stopped after 3 days in patients with low serum PCT cannot be substantiated statistically. Thus, the results of this study are inconclusive regarding the noninferiority of the PCT-guided plan compared to the standard antibiotic treatment. The study was funded by Agenzia Italiana del Farmaco (AIFA-FARM58J2XH). Clinical trial registered with www.clinicaltrials.gov (NCT01125098). ClinicalTrials.gov NCT01125098.
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    ABSTRACT: Accumulating evidence supports procalcitonin (PCT) as an accurate surrogate biomarker for likelihood and severity of bacterial infections. In community-acquired pneumonia and other respiratory infections, PCT-guided antibiotic therapy algorithms resulted in reduced antibiotic exposure while maintaining a similar or even better level of safety compared with standard care. Reductions in antibiotic use translate into lower treatment costs, decreased risk of side effects and decreased bacterial multiresistance. This is especially important, as acute respiratory infections represent the most frequent reason for antibiotic prescriptions worldwide. Still, there is some controversy about the benefits of PCT measurement in sepsis patients in the intensive care unit and for nonrespiratory infections. Highly sensitive PCT assays are readily available in many hospitals today, and point-of-care assays with high enough sensitivity for antibiotic guidance are expected to be available soon. Herein, the authors provide an overview of recent studies evaluating PCT in different clinical situations and an outlook of currently enrolling or upcoming interventional trials.
    Full-text · Article · Apr 2013 · Expert Review of Respiratory Medicine
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    ABSTRACT: Close monitoring and repeated risk assessment of sepsis patients in the intensive care unit (ICU) is important for decisions regarding care intensification or early discharge to the ward. We studied whether considering plasma kinetics of procalcitonin, a biomarker of systemic bacterial infection, over the first 72 critical care hours improved mortality prognostication of septic patients from two US settings. This retrospective analysis included consecutively treated eligible adults with a diagnosis of sepsis from critical care units in two independent institutions in Clearwater, Florida and Chicago, Illinois. Cohorts were used for derivation or validation to study the association of procalcitonin change over the first 72 critical care hours and mortality. ICU/in-hospital mortality rates were 29.2%/31.8% in the derivation cohort (n=154) and 17.6%/29.4% in the validation cohort (n=102). In logistic regression analysis of both cohorts, procalcitonin change was strongly associated with ICU and in-hospital mortality independent of clinical risk scores (APACHE IV or SAPS II), with area under the curve (AUC) from 0.67-0.71. When procalcitonin decreased by at least 80%, the negative predictive value for ICU/in-hospital mortality was 90%/90% in the derivation cohort, and 91%/79% in the validation cohort. When procalcitonin showed no decrease or increased, the respective positive predictive values were 48%/48% and 36%/52%. In septic patients, procalcitonin kinetics over the first 72 critical care hours provide prognostic information beyond that from clinical risk scores. If these observations are confirmed, procalcitonin monitoring may assist physician decision-making regarding care intensification or early transfer from ICU to the floor.
    Full-text · Article · Jun 2013 · Critical care (London, England)
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