Procalcitonin and lung ultrasonography point-of-care testing to determine antibiotic prescription in patients with lower respiratory tract infection in primary care: pragmatic cluster randomised trial

Abstract

Objective To assess whether point-of care procalcitonin and lung ultrasonography can safely reduce unnecessary antibiotic treatment in patients with lower respiratory tract infections in primary care. Design Three group, pragmatic cluster randomised controlled trial from September 2018 to March 2020. Setting 60 Swiss general practices. Participants One general practitioner per practice was included. General practitioners screen all patients with acute cough; patients with clinical pneumonia were included. Interventions Randomisation in a 1:1:1 of general practitioners to either antibiotics guided by sequential procalcitonin and lung ultrasonography point-of-care tests (UltraPro; n=152), procalcitonin guided antibiotics (n=195), or usual care (n=122). Main outcomes Primary outcome was proportion of patients in each group prescribed an antibiotic by day 28. Secondary outcomes included duration of restricted activities due to lower respiratory tract infection within 14 days. Results 60 general practitioners included 469 patients (median age 53 years (interquartile range 38-66); 278 (59%) were female). Probability of antibiotic prescription at day 28 was lower in the procalcitonin group than in the usual care group (0.40 v 0.70, cluster corrected difference −0.26 (95% confidence interval −0.41 to −0.10)). No significant difference was seen between UltraPro and procalcitonin groups (0.41 v 0.40, −0.03 (−0.17 to 0.12)). The median number of days with restricted activities by day 14 was 4 days in the procalcitonin group and 3 days in the usual care group (difference 1 day (95% confidence interval −0.23 to 2.32); hazard ratio 0.75 (95% confidence interval 0.58 to 0.97)), which did not prove non-inferiority. Conclusions Compared with usual care, point-of-care procalcitonin led to a 26% absolute reduction in the probability of 28 day antibiotic prescription without affecting patients’ safety. Point-of-care lung ultrasonography did not further reduce antibiotic prescription, although a potential added value cannot be excluded, owing to the wide confidence intervals. Trial registration ClinicalTrials.gov NCT03191071 .

Point-of-care procalcitonin testing for lower respiratory tract infection in pulmonary outpatient care has limited value

“…PCT has emerged as a powerful biomarker for the early diagnosis of sepsis, blood stream infections and for monitoring infections to determine length of antibiotic treatment [12,13]. However, POCT PCT testing to determine antibiotic prescription in patients with lower respiratory tract infection in primary care in favor of AMS, as it is recommended by Lhopitallier et al [3], is likely not sufficiently sensitive to distinguish between pneumonia and other causes of LRTI in the outpatient setting. The mentioned study of Lhopitalier et al report on a cohort of patients with clinically diagnosed pneumonia.…”

Pulse Oximetry as an Aid to Rule Out Pneumonia among Patients with a Lower Respiratory Tract Infection in Primary Care

“…This is a secondary analysis of a three-group cluster randomized trial which evaluated the impact of using procalcitonin and lung ultrasonography to reduce antibiotic prescriptions for clinical pneumonia in comparison to typical care across 60 primary care practices in Switzerland [ 13 ]. General practitioners included adult patients (aged 18 or over) presenting with clinical pneumonia as defined by the European guidelines for community-acquired pneumonia (an acute cough and at least one of the following: focal abnormal finding upon lung auscultation, dyspnea, tachypnea, or a history of fever > 4 days) between September 2018 and March 2020 [ 6 ].…”

Diagnostic and Prognostic Roles of Procalcitonin and Other Markers in Pneumonia: A Literature Update

“…While data directly supporting PCT-guided antibiotic decision-making in outpatients with CAP are limited, one randomized trial comparing >150 outpatients with CAP found that clinical outcomes were similar and antibiotic exposure was decreased when PCT was used (107). A recent study evaluated 469 general practice patients with any kind of respiratory infections (108). Antibiotic use was reduced at a rate of 26% when PCT was used to guide antibiotic decision-making, while clinical outcomes were similar.…”