Serum Procalcitonin Measurement and Viral Testing to Guide Antibiotic Use for Respiratory Infections in Hospitalized Adults: A Randomized Controlled Trial

Branche, Angela; Walsh, Edward E.; Vargas, Roberto L.; Hulbert, Barbara; Formica, Maria A.; Baran, Andrea; Peterson, Derick R.; Falsey, Ann R.

doi:10.1093/infdis/jiv252

Cited by 108 publications

(113 citation statements)

References 34 publications

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“…However, a number of previous studies have shown that patients with viral diseases had PCT levels <0.5 ng/mL [37,38]. In our study, PCT ≥0.7 ng/mL was independently associated with dengue shock and/or organ failure.…”

Section: Discussioncontrasting

confidence: 44%

Serum Procalcitonin and Peripheral Venous Lactate for Predicting Dengue Shock and/or Organ Failure: A Prospective Observational Study

et al. 2016

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BackgroundCurrently, there are no biomarkers that can predict the incidence of dengue shock and/or organ failure, although the early identification of risk factors is important in determining appropriate management to reduce mortality. Therefore, we sought to determine the factors associated with dengue shock and/or organ failure and to evaluate the prognostic value of serum procalcitonin (PCT) and peripheral venous lactate (PVL) levels as biomarkers of dengue shock and/or organ failure.Methodology/Principal FindingsA prospective observational study was conducted among adults hospitalized for confirmed viral dengue infection at the Hospital for Tropical Diseases in Bangkok, Thailand between October 2013 and July 2015. Data, including baseline characteristics, clinical parameters, laboratory findings, serum PCT and PVL levels, management, and outcomes, were recorded on pre-defined case report forms. Of 160 patients with dengue, 128 (80.0%) patients had dengue without shock or organ failure, whereas 32 (20.0%) patients developed dengue with shock and/or organ failure. Using a stepwise multivariate logistic regression analysis, PCT ≥0.7 ng/mL (odds ratio [OR]: 4.80; 95% confidence interval [CI]: 1.60–14.45; p = 0.005) and PVL ≥2.5 mmol/L (OR: 27.99, 95% CI: 8.47–92.53; p <0.001) were independently associated with dengue shock and/or organ failure. A combination of PCT ≥0.7 ng/mL and PVL ≥2.5 mmol/L provided good prognostic value for predicting dengue shock and/or organ failure, with an area under the receiver operating characteristics curve of 0.83 (95% CI: 0.74–0.92), a sensitivity of 81.2% (95% CI: 63.6–92.8%), and a specificity of 84.4% (95% CI: 76.9–90.2%). Dengue shock patients with non-clearance of PCT and PVL expired during hospitalization.Conclusions/SignificancePCT ≥0.7 ng/mL and PVL ≥2.5 mmol/L were independently associated with dengue shock and/or organ failure. The combination of PCT and PVL levels could be used as prognostic biomarkers for the prediction of dengue shock and/or organ failure.

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Section: Discussioncontrasting

confidence: 44%

Serum Procalcitonin and Peripheral Venous Lactate for Predicting Dengue Shock and/or Organ Failure: A Prospective Observational Study

et al. 2016

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“…The PSI score [18] had also been used in that cohort to classify patients according to severity. For comparability with our study group, we selected only patients with PSI risk classes I and II who met the inclusion/exclusion criteria.…”

Section: Resultsmentioning

confidence: 99%

Procalcitonin for selecting the antibiotic regimen in outpatients with low-risk community-acquired pneumonia using a rapid point-of-care testing: A single-arm clinical trial

et al. 2017

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ObjectiveWe aimed to assess the role of procalcitonin (PCT) to guide the initial selection of the antibiotic regimen for low-risk community-acquired pneumonia (CAP).MethodsA single-arm clinical trial was conducted including outpatients with CAP and Pneumonia Severity Index risk classes I-II. Antimicrobial selection was based on the results of PCT measured with a rapid point-of-care testing. According to serum PCT levels, patients were assigned to two treatment strategies: oral azithromycin if PCT was <0.5 ng/ml, or levofloxacin if levels were ≥0.5 ng/ml. Primary outcome was clinical cure rate. Short-term and long-term outcomes were assessed. Results were compared with those of a historical standard-of-care control-group treated in our centre.ResultsOf 253 subjects included, 216 (85.4%) were assigned to azithromycin. Pneumococcal infection was diagnosed in 26 (12%) and 21 (56.8%) patients allocated to azithromycin and levofloxacin groups, respectively. No patients in the azithromycin group developed bacteraemia. Atypical organisms were more common in patients given azithromycin (18.5% vs 8.1%, respectively). The majority (93%) of patients with atypical pneumonia had low PCT levels. Clinical cure rates were 95.8% in the azithromycin group, 94.6% in the levofloxacin group, and 94.4% in the historical control group. No 30-day mortality or recurrences were observed, and the 3-year rates of recurrence and mortality were very low in both groups. Adverse events occurrence was also infrequent.ConclusionA PCT-guided strategy with a rapid point-of-care testing safely allowed selecting empirical narrow-spectrum antibiotics in outpatients with CAP.Trial registrationThe study is registered with ClinicalTrials.gov, number NCT02600806

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“…The impact of PCT monitoring in patients with LRTIs was studied in a variety of randomized controlled trials, mainly in the inpatient setting (Table ). Overall, studies in this patient population demonstrated that PCT monitoring, when compared with standard care (no PCT monitoring), results in a reduction in antibiotic therapy duration in the range of 0–8 days, with no corresponding impact on infection relapses . A large meta‐analysis detected a significant reduction in 30‐day mortality in patients with acute respiratory infections receiving PCT‐guided therapy compared with those receiving standard care (9% vs 10%; adjusted OR 0.83, 95% CI 0.70–0.99, p=0.37, respectively) .…”

Section: Procalcitonin As a Determinant Of Antibiotic Therapy Durationmentioning

confidence: 87%

“…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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Serum Procalcitonin Measurement and Viral Testing to Guide Antibiotic Use for Respiratory Infections in Hospitalized Adults: A Randomized Controlled Trial

Abstract: NCT01907659.

Cited by 108 publications

References 34 publications

Serum Procalcitonin and Peripheral Venous Lactate for Predicting Dengue Shock and/or Organ Failure: A Prospective Observational Study

Serum Procalcitonin and Peripheral Venous Lactate for Predicting Dengue Shock and/or Organ Failure: A Prospective Observational Study

Procalcitonin for selecting the antibiotic regimen in outpatients with low-risk community-acquired pneumonia using a rapid point-of-care testing: A single-arm clinical trial

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

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