Procalcitonin-Guided Antibiotic Therapy Reduces Antibiotic Use for Lower Respiratory Tract Infections in a United States Medical Center: Results of a Clinical Trial

Abstract

BackgroundEuropean trials using procalcitonin (PCT)-guided antibiotic therapy for patients with lower respiratory tract infections (LRTIs) have demonstrated significant reductions in antibiotic use without increasing adverse outcomes. Few studies have examined PCT for LRTIs in the United States.MethodsIn this study, we evaluated whether a PCT algorithm would reduce antibiotic exposure in patients with LRTI in a US hospital. We conducted a controlled pre-post trial comparing an intervention group of PCT-guided antibiotic therapy to a control group of usual care. Consecutive patients admitted to medicine services and receiving antibiotics for LRTI were enrolled in the intervention. Providers were encouraged to discontinue antibiotics according to a PCT algorithm. Control patients were similar patients admitted before the intervention.ResultsThe primary endpoint was median antibiotic duration. Overall adverse outcomes at 30 days comprised death, transfer to an intensive care unit, antibiotic side effects, Clostridium difficile infection, disease-specific complications, and post-discharge antibiotic prescription for LRTI. One hundred seventy-four intervention patients and 200 controls were enrolled. Providers complied with the PCT algorithm in 75% of encounters. Procalcitonin-guided therapy reduced median antibiotic duration for pneumonia from 7 days to 6 (P = .045) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) from 4 days to 3 (P = .01). There was no difference in the rate of adverse outcomes in the PCT and control groups.ConclusionsA PCT-guided algorithm safely reduced the duration of antibiotics for treating LRTI. Utilization of a PCT algorithm may aid antibiotic stewardship efforts.This clinical trial was a single-center, controlled, pre-post study of PCT-guided antibiotic therapy for LRTI. The intervention (incorporation of PCT-guided algorithms) started on April 1, 2017: the preintervention (control group) comprised patients admitted from November 1, 2016 to April 16, 2017, and the postintervention group comprised patients admitted from April 17, 2017 to November 29, 2017 (Supplementary Figure 1). The study comprised patients admitted to the internal medicine services to a medical ward, the Medical Intensive Care Unit (MICU), the Cardiac Intensive Care Unit (CICU), or the Progressive Care Unit (PCU) “step down unit”. The registration data for the trails are in the ClinicalTrials.gov database, number NCT0310910.

Clinical Progress Note: Procalcitonin in the Diagnosis and Management of Community‐Acquired Pneumonia in Hospitalized Adults

“…For cases of proven bacterial etiology or high clinical suspicion of bacterial CAP, there is insufficient evidence to recommend the early discontinuation of antibiotics based on procalcitonin levels short of the recommended five-day course according to current guidelines. 10 Future clinical trials are needed to determine if procalcitonin guidance can safely decrease the duration of antibiotic therapy for confirmed bacterial CAP to less than five days.…”

Procalcitonin for Antibiotic Prescription in Chronic Obstructive Pulmonary Disease Exacerbations: Systematic Review, Meta-Analysis, and Clinical Perspective

“…A total of 14 studies were included in the metaanalysis of PCT as a biomarker for COPD exacerbation ( Fig. 1) [6,[13][14][15][16][17][18][19][20][21][22][23][24][25]. Reasons for excluding studies are summarized in Supplementary Appendix 2; the most common reason for excluding a study was the lack of reported data specifically on COPD exacerbation.…”

“…For observational studies, three studies used a before-after study design, and appropriate selection of a non-exposed group was unclear [13,18,25]. The existence of comorbidity was not comparable between exposed and non-exposed groups in one study [18].…”

To Procalcitonin, or Not to Procalcitonin?

“…Regarding antibiotic utilization, three other studies [7][8][9] have just been published after Pepper et al Huang et al 7 and van der Does et al 8 were randomized trials performed in the ED to evaluate antibiotic use; both failed to demonstrate antibiotic reduction with PCT. Both trials included a small number of patients with confirmed bacterial infection (30%-35%), low proportion of patients with pneumonia (20%-30%), low adherence with study protocol (60%-65%), a few patients who needed ICU admission (4%-5%), and very low mortality (2%-3%).…”

“…In addition, the numerous PCT studies done over more than a decade for acute bronchitis and COPD exacerbation have demonstrated the efficacy and safety of short course of antibiotics, which has already changed the standard of care to just a few days of antibiotics now. 9 In more recent studies in COPD patients adjusting antibiotic duration according to standard of care recommendations in the control group, PCT algorithms failed to demonstrate reduction on antibiotic exposure. 10 Further, the case mix and the absence of critically ill patients indicate that neither of these two trials 7,8 would meet the inclusion criteria by Pepper et al The third study, by Towsend et al 9 had a quasiexperimental design that showed a significant reduction in antibiotic use in lower respiratory tract infections; however, this study's design would also not meet Pepper et al criteria.…”