Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial

Drozdov, Daniel; Schwarz, Stefanie; Kutz, Alexander; Grolimund, Eva; Rast, Anna Christina; Steiner, Deborah; Regez, Katharina; Schild, Ursula; Guglielmetti, M; Conca, Antoinette; Reutlinger, Barbara; Ottiger, Cornelia; Buchkremer, Florian; Haubitz, Sebastian; Blum, C; Huber, Andreas; Buergi, Ulrich; Schuetz, Philipp; Böck, Andreas; Fux, Christoph A; Müeller, Beat; Albrich, Werner C.

doi:10.1186/s12916-015-0347-y

Cited by 32 publications

(51 citation statements)

References 38 publications

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“…All potentially relevant studies cited in documents supplied by the test manufacturers had already been identified by bibliographic database searches. One additional publication was obtained through contact with the authors, 69 after searches had identified the study protocol. 47 Figure 1 shows the flow of studies through the review process, and Appendix 4 provides details, with reasons for exclusions, of all publications excluded at the full paper screening stage.…”

Section: Results Of the Assessment Of Clinical Effectiveness Assessmentmentioning

confidence: 99%

“…Eight studies were conducted in ICU settings 33,37,41,45,50,52,54,61 and all of these studies included only adult participants; we did not identify any studies conducted in paediatric ICU settings that met the inclusion criteria for this review. Ten studies 39,42,44,49,[55][56][57]60,62,69 were conducted in ED settings, of which eight included only adults 42,44,[55][56][57]60,62,69 and two included only children. 39,49 The majority (12 37,39,41,42,44,49,52,57,[60][61][62]69 ) of the included studies measured plasma/serum PCT levels using the BRAHMS PCT Sensitive Kryptor assay (Thermo Fisher Scientific Inc., Waltham, MA, USA).…”

Section: Overview Of Included Studiesmentioning

confidence: 99%

“…The two studies 55,56 that were published as conference abstracts did not specify location. Nine 37,39,41,42,44,52,57,60,61 of the 18 included studies reported receiving some support from assay manufacturers, including supply of assay platforms and/or kits; five studies 33,49,54,62,69 were fully supported by public funding and four studies 45,50,55,56 did not report any information on funding.…”

Section: Overview Of Included Studiesmentioning

confidence: 99%

“…Three 45,52,60 of the eighteen studies 33,37,39,41,42,44,45,49,50,52,[54][55][56][57][60][61][62]69 were judged at high risk of bias, one as low risk of bias, 62 and all other studies were judged at unclear risk of bias, as insufficient information was reported to make a judgement on one or more bias domains ( Figure 2 and Table 1). …”

Section: Study Qualitymentioning

confidence: 99%

“…Ten RCTs, 39,42,44,49,[55][56][57]60,62,69 reported in 16 publications, 39,40,[42][43][44][47][48][49][55][56][57][58][59]62,69,70 provided data on the effectiveness of adding PCT testing to the information used to guide antibiotic therapy in ED settings. Two studies 39,49 were conducted in children, and the remainder 42,44,[55][56][57]60,62,69 were conducted in all adult populations.…”

Section: Study Detailsmentioning

confidence: 99%

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Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Westwood

Ramaekers

Whiting

et al. 2015

Health Technol Assess

116

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BackgroundDetermination of the presence or absence of bacterial infection is important to guide appropriate therapy and reduce antibiotic exposure. Procalcitonin (PCT) is an inflammatory marker that has been suggested as a marker for bacterial infection.ObjectivesTo assess the clinical effectiveness and cost-effectiveness of adding PCT testing to the information used to guide antibiotic therapy in adults and children (1) with confirmed or highly suspected sepsis in intensive care and (2) presenting to the emergency department (ED) with suspected bacterial infection.MethodsTwelve databases were searched to June 2014. Randomised controlled trials were assessed for quality using the Cochrane Risk of Bias tool. Summary relative risks (RRs) and weighted mean differences (WMDs) were estimated using random-effects models. Heterogeneity was assessed visually using forest plots and statistically using theI2andQstatistics and investigated through subgroup analysis. The cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice using a decision tree with a 6 months’ time horizon.ResultsEighteen studies (36 reports) were included in the systematic review. PCT algorithms were associated with reduced antibiotic duration [WMD –3.19 days, 95% confidence interval (CI) –5.44 to –0.95 days,I2 = 95.2%; four studies], hospital stay (WMD –3.85 days, 95% CI –6.78 to –0.92 days,I2 = 75.2%; four studies) and a trend towards reduced intensive care unit (ICU) stay (WMD –2.03 days, 95% CI –4.19 to 0.13 days,I2 = 81.0%; four studies). There were no differences for adverse clinical outcomes. PCT algorithms were associated with a reduction in the proportion of adults (RR 0.77, 95% CI 0.68 to 0.87; seven studies) and children (RR 0.86, 95% CI 0.80 to 0.93) receiving antibiotics, reduced antibiotic duration (two studies). There were no differences for adverse clinical outcomes. All but one of the studies in the ED were conducted in people presenting with respiratory symptoms.Cost-effectiveness: the base-case analyses indicated that PCT testing was cost-saving for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED. Cost-savings ranged from £368 to £3268. Moreover, PCT-guided treatment resulted in a small quality-adjusted life-year (QALY) gain (ranging between < 0.001 and 0.005). Cost-effectiveness acceptability curves showed that PCT-guided treatment has a probability of ≥ 84% of being cost-effective for all settings and populations considered (at willingness-to-pay thresholds of £20,000 and £30,000 per QALY).ConclusionsThe limited available data suggest that PCT testing may be effective and cost-effective when used to guide discontinuation of antibiotics in adults being treated for suspected or confirmed sepsis in ICU settings and initiation of antibiotics in adults presenting to the ED with respiratory symptoms and suspected bacterial infection. However, it is not clear that observed costs and effects are directly attributable to PCT testing, are generalisable outside people presenting with respiratory symptoms (for the ED setting) and would be reproducible in the UK NHS. Further studies are needed to assess the effectiveness of adding PCT algorithms to the information used to guide antibiotic treatment in children with suspected or confirmed sepsis in ICU settings. Additional research is needed to examine whether the outcomes presented in this report are fully generalisable to the UK.Study registrationThis study is registered as PROSPERO CRD42014010822.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Results Of the Assessment Of Clinical Effectiveness Assessmentmentioning

confidence: 99%

Section: Overview Of Included Studiesmentioning

confidence: 99%

Section: Overview Of Included Studiesmentioning

confidence: 99%

Section: Study Qualitymentioning

confidence: 99%

Section: Study Detailsmentioning

confidence: 99%

See 3 more Smart Citations

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Westwood

Ramaekers

Whiting

et al. 2015

Health Technol Assess

116

View full text Add to dashboard Cite

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Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections

Schuetz

Wirz

Sager

et al. 2017

Cochrane Database of Systematic Reviews

333

168

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This updated meta-analysis of individual participant data from 12 countries shows that the use of procalcitonin to guide initiation and duration of antibiotic treatment results in lower risks of mortality, lower antibiotic consumption, and lower risk for antibiotic-related side effects. Results were similar for different clinical settings and types of ARIs, thus supporting the use of procalcitonin in the context of antibiotic stewardship in people with ARIs. Future high-quality research is needed to confirm the results in immunosuppressed patients and patients with non-respiratory infections.

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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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Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial

Cited by 32 publications

References 38 publications

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections

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

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