Dataset Information

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

ABSTRACT:

Background

Viral lower respiratory tract illness (LRTI) frequently causes adult hospitalization and is linked to antibiotic overuse. European studies suggest that the serum procalcitonin (PCT) level may be used to guide antibiotic therapy. We conducted a trial assessing the feasibility of using PCT algorithms with viral testing to guide antibiotic use in a US hospital.

Methods

Three hundred patients hospitalized with nonpneumonic LRTI during October 2013-April 2014 were randomly assigned at a ratio of 1:1 to receive standard care or PCT-guided care and viral PCR testing. The primary outcome was antibiotic exposure, and safety was assessed at 1 and 3 months.

Results

Among the 151 patients in the intervention group, viruses were identified in 42% (63), and 83% (126) had PCT values of <0.25 µg/mL. There were no significant differences in antibiotic use or adverse events between intervention patients and those in the nonintervention group. Subgroup analyses revealed fewer subjects with positive results of viral testing and low PCT values who were discharged receiving antibiotics (20% vs 45%; P = .002) and shorter antibiotic durations among algorithm-adherent intervention patients versus nonintervention patients (2.0 vs 4.0 days; P = .004). Compared with historical controls (from 2008-2011), antibiotic duration in nonintervention patients decreased by 2 days (6.0 vs 4.0 days; P < .001), suggesting a study effect.

Conclusions

Although antibiotic use was similar in the 2 arms, subgroup analyses of intervention patients suggest that physicians responded to viral and biomarker data. These data can inform the design of future US studies.

Clinical trials registration

NCT01907659.

SUBMITTER: Branche AR

PROVIDER: S-EPMC4633755 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:INTRODUCTION:The differentiation of viral from bacterial pneumonia is important in determining whether antibiotics are appropriate for treatment of these infections. Advances in diagnostic technologies such as respiratory panels (RP) utilizing polymerase chain reactions to detect viruses and determination of procalcitonin (PCT) concentrations may aid in this differentiation. However, some studies have shown limited impact for this purpose and thus continuation of antibiotics despite results suggesting viral infection. Our objective was to characterize clinician-prescribing behavior at our institution once RP and/or PCT results were known and suggestive of a viral respiratory infection. METHODS:This retrospective analysis was based upon records of hospitalized patients in whom proven or possible respiratory infections as indicated by RP testing, respiratory bacterial culture or International Statistical Classification of Diseases and Related Health Problems 9th revision codes for acute infectious respiratory illness was documented. Patients evaluated were required to have a RP or PCT within the first 72 h of presentation. Drug orders were evaluated for discontinuation of antibiotic therapy within 48 h of a procalcitonin of <0.25 μg/mL, a positive viral RP result, or both. RESULTS:Of 4869 patients with PCT and/or RP results, 2031 were included. PCT and RP testing were obtained in 503 and 1823 patients, respectively, with 295 patients having both. Results of these tests suggested 789 patients were potential candidates for antibiotic avoidance. These included 219 with a PCT <0.25 μg/mL, 601 with a positive viral RP result, and 31 with both. Antibiotics were administered to 307 patients (39%) within the first 72 h. In these, antibiotics were discontinued within 48 h of laboratory results availability. CONCLUSION:These results suggest that positive viral RP and low PCT results are infrequently associated with discontinuation of antibiotic therapy in proven or possible respiratory infections at our institution. Direct interventions with clinicians are likely needed to correct this behavior and decrease unnecessary antibiotic use.