Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study

Abstract

In patients with ventilator-associated pneumonia (VAP), guidelines recommend antibiotic therapy adjustment according to microbiology results after 72 h. Circulating procalcitonin levels may provide evidence that facilitates the reduction of antibiotic therapy.In a multicentre, randomised, controlled trial, 101 patients with VAP were assigned to an antibiotic discontinuation strategy according to guidelines (control group) or to serum procalcitonin concentrations (procalcitonin group) with an antibiotic regimen selected by the treating physician. The primary end-point was antibiotic-free days alive assessed 28 days after VAP onset and analysed on an intent-to-treat basis.Procalcitonin determination significantly increased the number of antibiotic free-days alive 28 days after VAP onset (13 (2-21) days versus 9.5 (1.5-17) days). This translated into a reduction in the overall duration of antibiotic therapy of 27% in the procalcitonin group (p50.038). After adjustment for age, microbiology and centre effect, the rate of antibiotic discontinuation on day 28 remained higher in the procalcitonin group compared with patients treated according to guidelines (hazard rate 1.6, 95% CI 1.02-2.71). The number of mechanical ventilation-free days alive, intensive care unit-free days alive, length of hospital stay and mortality rate on day 28 for the two groups were similar.Serum procalcitonin reduces antibiotic therapy exposure in patients with ventilator associated pneumonia.

Plasma Procalcitonin: Another Arrow in Our Quiver?

“…This reduction in antibiotic administration was not associated with a worse outcome, since ventilator-free days, ICU-free days, hospital stay, 28-day mortality, and hospital mortality rate were similar in the 2 groups. 18 Similar results were observed by Bouadma et al in the Use of Procalcitonin to Reduce Patients' Exposure to Antibiotics in Intensive Care Units (PRORATA) trial, a randomized trial that included 621 ICU patients, of whom 141 had microbiologically proven VAP. Using predefined algorithms to initiate or discontinue antibiotics according to serum procalcitonin level, the duration of antibiotic treatment for the first episode was also significantly decreased in the 75 patients randomized in the procalcitonin-guided group, compared to the control group managed using international and local guidelines (7.3 Ϯ 5.3 d vs 9.4 Ϯ 5.7 d, respectively, P ϭ .02), with no detrimental effects on patient outcomes.…”

“…18,19 Stolz et al randomized 101 patients with VAP to be managed with an antibiotic discontinuation strategy according to guidelines (control group) or to serum procalcitonin concentration. In patients randomized in the procalcitonin group, attending physicians were recommended to stop antibiotics when the procalcitonin concentration was below 0.5 ng/mL or had decreased by more than 80% from the baseline value.…”

La procalcitonina in Terapia Intensiva: un grande futuro alle spalle?

“…• Stolz et al [12] hanno pubblicato nel 2009 un trial multicentrico randomizzato in 7 UU.OO. di Terapia Intensiva in Europa e USA comprendente 101 pazienti trattati con antibiotici.…”

The Characteristics of Antibiotic Use and Changing Patterns in an Intensive Care Unit

“…The debate of biomarker guided antibiotic therapy is ongoing. Two-center randomized controlled trial demonstrated that measuring daily PCT and using PCT guidance for antibiotic initiation and withholding resulted in a decrease in overall antibiotic use from 15 to 10 days in 101 patients with ventilator associated pneumonia (VAP) (24). In a French study (25) on non-surgical patients with suspected bacterial infection (73% with a respiratory infection) in seven ICUs, PCT-guided treatment initiation and discontinuation provided 23% more antibiotic free days compared to the control group (25).…”