Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis

Schuetz, Philipp; Wirz, Yannick; Sager, Ramon; Christ‐Crain, Mirjam; Stolz, Daiana; Tamm, Michael; Bouadma, Lila; Luyt, Charles Edouard; Wolff, Michel; Chastre, Jean; Tubach, Florence; Kristoffersen, Kristina B; Burkhardt, Olaf; Welte, Tobias; Schroeder, Stefan; Nobre, Vandack; Long, Wei; Bucher, Heiner C.; Annane, Djillali; Reinhart, Konrad; Falsey, Ann R.; Branche, Angela; Damas, Pierre; Nijsten, Maarten W. N.; Lange, Dylan W. de; Deliberato, Rodrigo Octávio; Oliveira, Carolina; Maravić-Stojković, Vera; Verduri, Alessia; Beghè, Bianca; Cao, Bin; Shehabi, Yahya; Jensen, Jens Ulrik Stæhr; Corti, Caspar; Oers, Jos A H van; Beishuizen, Albertus; Girbes, Armand R.J.; Jong, Evelien de; Briel, Matthias; Müeller, Beat

doi:10.1016/s1473-3099(17)30592-3

Cited by 353 publications

(278 citation statements)

References 61 publications

(37 reference statements)

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“…The authors cited modest adherence and lack of serial PCT measurements as potential factors contributing to the lack of observed benefits. In other studies, adherence to PCT algorithms varies greatly, ranging from 47–97% …”

Section: Challenges Implementing Pct Monitoringmentioning

confidence: 98%

Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature

2018

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Effective antimicrobial stewardship practices are increasingly essential to best utilize the current arsenal of antimicrobials for the shortest necessary duration to minimize the development of antimicrobial resistance, secondary infections, and health care costs. Monitoring of serum procalcitonin (PCT) levels represents an effective antimicrobial stewardship strategy to differentiate bacterial infections from viral infections and noninfectious inflammatory conditions. Current literature illustrates the merits of PCT monitoring in reducing duration of antibiotic therapy without detrimental effects on mortality or infection relapses. However, the interpretation of PCT levels can be challenging, especially in light of comorbid disease states that can elevate PCT levels. This review sheds light on the utility of PCT monitoring, as well as providing insight into the practical interpretation of PCT levels. Much of the current literature surrounding PCT monitoring consists of use among patients with lower respiratory tract infections or in the critically ill. Overall, studies have demonstrated shorter antibiotic therapy durations when PCT monitoring is utilized. No studies to date have found increased rates of mortality or infection relapses, suggesting that PCT monitoring is not only effective, but also safe when used as a guide for antimicrobial therapy. Nonetheless, many conditions were shown to elevate PCT serum concentrations, even in the absence of bacterial infections, which can make interpretation of PCT concentrations challenging. Two common conditions that affect the accurate interpretation of PCT levels are renal dysfunction and congestive heart failure. Limited studies have been performed in these populations, but current available data propose the need for higher PCT thresholds in those with renal dysfunction or congestive heart failure and support utilizing PCT trends to monitor clinical improvement from bacterial infections. Evidence also suggests that PCT monitoring is cost-effective, as long as the test is ordered judiciously. In summary, PCT monitoring represents a promising antimicrobial stewardship strategy to limit exposure to unnecessary antimicrobial therapy.

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Section: Challenges Implementing Pct Monitoringmentioning

confidence: 98%

Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature

2018

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“…Therefore, whether these or other screening tools can be validated in a prospective and larger study, particularly in an LTCF setting, remains to be determined. Serum level of procalcitonin was used as an indicator for respiratory infections and sepsis . However, studies of procalcitonin in LTCF residents are too few to reach definitive conclusions …”

Section: Next Steps and Recommendationsmentioning

confidence: 99%

Sepsis in Older Adults in Long‐Term Care Facilities: Challenges in Diagnosis and Management

Yoshikawa

Reyes

Ouslander

2019

J American Geriatrics Society

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Despite the current understanding of the pathophysiology of sepsis and advances in its treatment, the rate of sepsis is increasing globally. Sepsis is a common cause of hospitalization in older adults, and infections are among the most common diagnoses among residents transferred to the hospital from long‐term care facilities (LTCFs). LTCFs and hospitals are facing financial and regulatory requirements to reduce potentially preventable emergency department visits, hospitalizations, and hospital readmissions due to infections and other causes. In addition, the human and financial costs of these events are substantial. Current criteria for early identification of sepsis have low sensitivity and specificity among LTCF residents. Early diagnosis must focus on changes in clinical, mental, and functional status, and vital signs including pulse oximetry. Laboratory data can increase the suspicion of sepsis, but the availability of testing and timing of results limits its usefulness in most LTCFs.While new diagnostic criteria for sepsis are being developed and validated in the LTCF setting, clinical practice and decision support tools are available to guide management. Most LTFCs do not have the capabilities to manage sepsis based on current guidelines despite availability of qualified nursing staff and clinicians. Thus excluding circumstances in which a resident's desire is palliative or hospice care without transfer to a hospital, most LTCFs will continue to transfer residents with severe infections at risk for evolving into sepsis to an acute hospital setting. J Am Geriatr Soc 67:2234–2239, 2019

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“…In the presence of sepsis, its plasma concentration increases and returns towards normal faster than white blood cell count and CRP, conferring a potential advantage over these for clinical decision making . A recent meta‐analysis suggested a reduced risk of mortality and broad spectrum antibiotic use associated with the use of PCT‐based algorithms in different clinical settings . However, there are fewer data on use of PCT to guide the diagnosis of sepsis in ED, and thus PCT is not currently recommended to rule out sepsis in the ED (Table ).…”

Section: Biomarkersmentioning

confidence: 99%

“…20 A recent meta-analysis suggested a reduced risk of mortality and broad spectrum antibiotic use associated with the use of PCT-based algorithms in different clinical settings. 21 However, there are fewer data on use of PCT to guide the diagnosis of sepsis in ED, and thus PCT is not currently recommended to rule out sepsis in the ED 22 (Table 2). Future studies are required to investigate its potential to rule-in or rule-out sepsis.…”

Section: Confirmation Of Infectionmentioning

confidence: 99%

Review article: Sepsis in the emergency department – Part 2: Investigations and monitoring

Shetty

Macdonald

Keijzers

et al. 2018

Emerg Medicine Australasia

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Sepsis is characterised by organ dysfunction resulting from infection, with no reliable single objective test and current diagnosis based on clinical features and results of investigations. In the ED, investigations may be conducted to diagnose infection as the cause of the presenting illness, identify the source, distinguish sepsis from uncomplicated infection (i.e. without organ dysfunction) and/ or risk stratification. Appropriate sample collection for microbiological testing remains key for subsequent confirmation of diagnosis and rationalisation of antimicrobials. Routine laboratory investigations such as creatinine, bilirubin, platelet count and lactate are now critical elements in the diagnosis of sepsis and septic shock. With no biomarker sufficiently validated to rule out bacterial infection in the ED, there remains substantial interest in biomarkers representing various pathogenic pathways. New technologies for screening multiple genes and proteins are identifying unique network 'signatures' of clinical interest. Other future directions include rapid detection of bacterial DNA in blood, genes for antibiotic resistance and EMR-based computational biomarkers that collate multiple information sources. Reliable, cost-effective tests, validated in the ED to promptly and accurately identify sepsis, and to guide initial antibiotic choices, are important goals of current research efforts.

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Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis

Abstract: National Institute for Health Research.

Cited by 353 publications

References 61 publications

Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature

Procalcitonin Monitoring as a Guide for Antimicrobial Therapy: A Review of Current Literature

Sepsis in Older Adults in Long‐Term Care Facilities: Challenges in Diagnosis and Management

Review article: Sepsis in the emergency department – Part 2: Investigations and monitoring

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