When once is not enough--further evidence of procalcitonin-guided antibiotic stewardship.
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ABSTRACT:
SUBMITTER: Harbarth S
PROVIDER: S-EPMC2750139 | biostudies-other | 2009
REPOSITORIES: biostudies-other
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When once is not enough--further evidence of procalcitonin-guided antibiotic stewardship.
Harbarth Stephan S Albrich Werner C WC Müller Beat B
Critical care (London, England) 20090713 4
Every day, critical care physicians around the world face the same challenge of the optimal timing of antimicrobial administration: when to start and when to stop antibiotics. Duration of antibiotic therapy for sepsis is mostly based on expert opinion, but its reduction is arguably the most promising approach to decrease emergence and selection of antibiotic resistance. The study by Hochreiter and colleagues presents another piece of evidence suggesting that procalcitonin may indeed be a valuabl ...[more]
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Project description:Several controlled clinical studies have evaluated the potential of the infection biomarker procalcitonin (PCT) to improve the diagnostic work-up of patients with bacterial infections and its influence on decisions regarding antibiotic therapy. Most research has focused on lower respiratory tract infections and critically ill sepsis patients. A clinical utility for PCT has also been found for patients with urinary tract infections, postoperative infections, meningitis, and patients with acute heart failure with possible superinfection (i.e., pneumonia). In these indications, PCT levels measured on hospital admission were found to substantially reduce the initiation of antibiotic treatment in low-risk situations (i.e., bronchitis, chronic obstructive pulmonary disease exacerbation). For more severe infections (i.e., pneumonia, sepsis), antibiotic stewardship by monitoring of PCT kinetics resulted in shorter antibiotic treatment durations with early cessation of therapy. Importantly, these strategies appear to be safe without increasing the risk for mortality, recurrent infections, or treatment failures. PCT kinetics also proved to have prognostic value correlating with disease severity (i.e., pancreatitis, abdominal infection) and resolution of illness (i.e., sepsis). Although promising findings have been published in these different types of infections, there are a number of limitations regarding PCT, including suboptimal sensitivity and/or specificity, which makes a careful interpretation of PCT in the clinical context mandatory. This narrative review aims to update clinicians on the strengths and limitations of PCT for patient management, focusing on research conducted within the last 4 years.
| S-EPMC5259962 | biostudies-literature
Project description:Delayed pathogen identification and nonspecific clinical findings make definitive decisions regarding antibiotics challenging. The stimuli of bacterial toxins and inflammation make procalcitonin (PCT) unique in its ability to differentiate bacterial infection from other causes of inflammation, and thus it is useful for antibiotic management. The objective of our study was to evaluate the impact of a PCT algorithm (PCT-A) on current practice.A single-center, retrospective cohort study was conducted to evaluate the impact of adding PCT-A to stewardship practices. Data from 4 years prior to and after PCT-A implementation were compared in critical and acute care patients of all ages receiving parenteral antibiotics for a DRG coded for infection. A baseline PCT was obtained on admission in patients with suspected bacterial infection. Serial PCT measurements were repeated daily to evaluate effectiveness of therapy. Outcomes of interest were antibiotic exposure, hospital mortality, 30-day readmission, Clostridium difficile infection (CDI), and adverse drug events during hospitalization.A total of 985 patients (pre-PCT-A group) were compared with 1167 patients (post-PCT-A group). Antimicrobial stewardship alone (pre-PCT-A) resulted in a median days of therapy (DOT) of 17 (interquartile range [IQR], 8.5-22.5) vs 9.0 (IQR, 6.5-12) in the post-PCT-A group (P < .0001). Secondary outcomes were also significantly reduced in the post-PCT-A group.The addition of PCT in a facility with an established stewardship program resulted in a significant reduction in antibiotic exposure and adverse outcomes. PCT may improve antibiotic management when diagnostic clarity and resolution of infection are lacking.
| S-EPMC5695623 | biostudies-literature
Project description:Procalcitonin (PCT) was discovered as a useful marker for bacterial infection. Following its discovery, there have been a substantial number of clinical studies conducted to evaluate the presence of bacterial infections, and to guide antibiotic treatment by the stratified levels of PCT. Clinical evidence suggests that antibiotic treatment by PCT-guided antibiotic stewardship has been associated with a reduction in antibiotic usage without an increase in adverse outcomes. The use of PCT was approved by the Food and Drug Administration in the United States of America in 2017 to guide antibiotic treatment in sepsis and lower respiratory tract infections (LRTIs). In Korea, the use of PCT for sepsis and for pneumonia was approved in 2015 and 2022, respectively. This review will discuss the clinical utility of PCT on antibiotic stewardship in the management of sepsis and LRTIs including pneumonia.
| S-EPMC9840962 | biostudies-literature
Project description:Reducing antibiotics overuse is essential to minimize antibiotics related side effects and to prevent the emergence of multidrug-resistant bacteria. Procalcitonin (PCT) guided antibiotics therapy has been reported to be safe in patients with acute respiratory infections and sepsis, improving clinical outcomes as well as reducing the duration of antibiotics use. However, there is still no universal agreement on clinical guidelines in Korea for optimal PCT applications. Through this expert consensus meeting, clinical research findings in the PCT-guided antibiotics treatment interventions and real-world clinical applications were discussed. From the perspective of antibiotic stewardship, PCT application target groups, cut-offs, and testing cycles were discussed to reach a consensus on the PCT-guided antibiotics treatment algorithm for application in Korea. Combining clinical assessment for patients with an appropriate PCT-guided antibiotics treatment algorithm could improve the diagnosis and treatment of acute respiratory infections and sepsis. In addition, continuous education and regular feedback would improve the effectiveness of antibiotic stewardship.
| S-EPMC9840958 | biostudies-literature
Project description:BackgroundProcalcitonin is a biomarker that may be able to identify patients with COVID-19 pneumonia who do not require antimicrobials for bacterial respiratory tract co-infections.ObjectivesTo evaluate the safety and effectiveness of a procalcitonin-guided algorithm in rationalizing empirical antimicrobial prescriptions in non-critically ill patients with COVID-19 pneumonia.MethodsRetrospective, single-site, cohort study in adults hospitalized with confirmed or suspected COVID-19 pneumonia and receiving empirical antimicrobials for potential bacterial respiratory tract co-infection. Regression models were used to compare the following outcomes in patients with and without procalcitonin testing within 72 h of starting antimicrobials: antimicrobial consumption (DDD); antimicrobial duration; a composite safety outcome of death, admission to HDU/ICU or readmission to hospital within 30 days; and length of admission. Procalcitonin levels of ≤0.25 ng/L were interpreted as negatively predictive of bacterial co-infection. Effects were expressed as ratios of means (ROM) or prevalence ratios (PR) accordingly.Results259 patients were included in the final analysis. Antimicrobial use was lower in patients who had procalcitonin measured within 72 h of starting antimicrobials: mean antimicrobial duration 4.4 versus 5.4 days, adjusted ROM 0.7 (95% CI 0.6-0.9); mean antimicrobial consumption 6.8 versus 8.4 DDD, adjusted ROM 0.7 (95% CI 0.6-0.8). Both groups had similar composite safety outcomes (adjusted PR 0.9; 95% CI 0.6-1.3) and lengths of admission (adjusted ROM 1.3; 95% CI 0.9-1.6).ConclusionsA procalcitonin-guided algorithm may allow for the safe reduction of antimicrobial usage in hospitalized non-critically ill patients with COVID-19 pneumonia.
| S-EPMC8378277 | biostudies-literature
Project description:BackgroundPneumonia is among the most common acute complications after stroke and is associated with poor long-term outcome. Biomarkers may help identifying stroke patients at high risk for developing stroke-associated pneumonia (SAP) and to guide early treatment.AimsThis trial investigated whether procalcitonin (PCT) ultrasensitive (PCTus)-guided antibiotic treatment of SAP can improve functional outcome after stroke.MethodsIn this international, multicenter, randomized, controlled clinical trial with blinded assessment of outcomes, patients with severe ischemic stroke in the middle cerebral artery territory were randomly assigned within 40 h after symptom onset to PCTus-based antibiotic therapy guidance in addition to stroke unit care or standard stroke unit care alone. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale (mRS) and dichotomized as acceptable (≤4) or unacceptable (≥5). Secondary endpoints included usage of antibiotics, infection rates, days of fever, and mortality. The trial was registered with http://ClinicalTrials.gov (Identifier NCT01264549).ResultsIn the intention-to-treat-analysis based on 227 patients (112 in PCT and 115 in control group), 197 patients completed the 3-month follow-up. Adherence to PCT guidance was 65%. PCT-guided therapy did not improve functional outcome as measured by mRS (odds ratio 0.79; 95% confidence interval 0.45-1.35, p = 0.47). Pneumonia rate and mortality were similar in both groups. Days with fever tended to be lower (p = 0.055), whereas total number of days treated with antibiotics were higher (p = 0.004) in PCT compared to control group. A post hoc analysis including all PCT values in the intention-to-treat population demonstrated a significant increase on the first day of infection in patients with pneumonia and sepsis compared to patients with urinary tract infections or without infections (p < 0.0001).ConclusionPCTus-guided antibiotic therapy did not improve functional outcome at 3 months after severe ischemic stroke. PCT is a promising biomarker for early detection of pneumonia and sepsis in acute stroke patients.
| S-EPMC5402305 | biostudies-literature
Project description:BackgroundAs a novel biomarker of inflammation, procalcitonin (PCT) has proven useful to guide antibiotic therapy in intensive care unit (ICU). However, there are controversial on mortality. The aim of this study was to evaluate the utility of PCT-guided antibiotic therapy in critically ill adults and determine whether studies are sufficient.MethodsA systematic search in PubMed, Embase and Cochrane was performed. We included only randomized controlled trials which compared the safety and efficacy between PCT-guided or standard antibiotic therapy groups in ICU adults. Trial sequential analysis and GARDE approach were performed.ResultsFifteen studies met our criteria for inclusion finally, with a cumulative number of 5486 ICU patients. There was no difference in 28-day mortality between two compared groups (P = 0.626), but significant decreases were observed in the duration of antibiotic therapy for the first episode of infection (P < 0.001) and length of hospitalization (P = 0.049). No significant deference was found in secondary endpoints except total duration of antibiotic therapy (P < 0.001). TSA revealed that the pooled sample sizes of 28-day mortality and the duration of antibiotic therapy for the first episode of infection exceeded the estimated required information size, but not the length of hospitalization.ConclusionsPCT-guided therapy is a better and safer algorithm to be applied into ICU patients, which appears no effect on 28-day mortality while performing preferable utility in reducing the duration of antibiotic therapy for the first episode of infection. More studies on these endpoints were not recommended.
| S-EPMC5525369 | biostudies-literature
Project description:BackgroundIn community-acquired pneumonia (CAP), the role of biomarkers to shorten duration of antibiotic treatment has not been firmly established. We assessed the effectiveness of active feedback of treatment algorithms based on procalcitonin (PCT) and C-reactive protein (CRP), compared to standard care, on the duration of antibiotic treatment in patients hospitalized with community-acquired pneumonia (CAP) in non-ICU wards.Methods and findingsWe performed a randomised, open label, parallel group, multi-centre trial in 3 Dutch teaching hospitals. Treatment was guided by a PCT algorithm, CRP algorithm or standard care. Participants were recruited by a member of the study team and randomised at day 2-3 of admission in a 1:1:1 ratio. Treatment was discontinued upon predefined thresholds of biomarkers that were assessed on admission, day 4 and days 5-7 if indicated. The primary outcome was total days on antibiotic treatment until day 30. In total 468 participants were included in this study. The median days on antibiotics (IQR) was 7 (IQR 7-10) in the control group, 4 (IQR 3-7) in the CRP group (rate ratio (RR) of 0.70, 95% CI 0.61-0.82 compared to standard care; p <0.001), and 5.5 (IQR 3-9) in the PCT group (RR of 0.78, 95% CI 0.68-0.89 compared to standard care; p <0.001). New antibiotics within the first 30 days were prescribed to 24, 23 and 35 patients in standard care, CRP and PCT groups, respectively. The hazard ratio for a new prescription in patients in the PCT group compared to standard care 1.63 (CI 0.97-2.75; p = 0.06). No difference in time to clinical stability or length of stay was found.ConclusionsA strategy of feedback of CRP-guided and PCT-guided treatment algorithms reduced the number of days on antibiotic in the first 30 days after hospital admission in non-ICU wards for CAP. The study was not powered to determine safety of shortening duration of antibiotic treatment. (NCT01964495).
| S-EPMC11335096 | biostudies-literature
Project description:BackgroundThe utility of procalcitonin testing in the pediatric intensive care unit (PICU) is not known. We sought to determine the impact of a procalcitonin-guided antibiotic treatment algorithm implemented with antibiotic stewardship (AS) guidance vs. usual care on antibiotic use in critically ill children.MethodsSingle center, pragmatic, randomized prospective clinical trial of critically ill children admitted to an ICU setting and started on intravenous antibiotics from February 15, 2018, to April 11, 2019. Patients were assigned on a monthly basis to either the procalcitonin or usual care arm. The procalcitonin arm had procalcitonin testing on hospital days 0, 1, 2, and 4 and stewardship assistance with algorithm result interpretation. Both arms had routine AS audit and feedback. The primary outcome was median antibiotic days of therapy per patient in the first 14-days after enrollment.ResultsAmong 270 patients, 137 were in the procalcitonin arm and 133 in the usual care arm. Antibiotic days of therapy (DOT) were not significantly different between the procalcitonin arm (6.6, IQR: 3.1-10.9) and the usual care arm (7.6, IQR: 3-11.8; P = 0.37). More AS recommendations were made in the procalcitonin vs. control arm (54 vs. 37; P = 0.03). Adherence with algorithm-based antibiotic recommendations was high in the procalcitonin arm (70%).ConclusionsWe found no difference in antibiotic DOT between study arms. This trial was underpowered but demonstrates feasibility of using a procalcitonin-guided antibiotic treatment algorithm with AS audit and feedback in the PICU.
| S-EPMC7954892 | biostudies-literature
Project description:BackgroundDespite the low rate of bacterial co-infection, antibiotics are very commonly prescribed in hospitalised COVID-19 patients.Research questionDoes the use of a PCT-guided antibiotic protocol safely reduce the use of antibiotics in patients with a COVID-19 infection?Study design and methodsIn this multicentre cohort, 3 groups of COVID-19 patients were compared in terms of antibiotic consumption, namely one group treated based on a PCT-algorithm in one hospital (n=216) and 2 control groups, consisted of patients from the same hospital (n=57) and of patients from 3 similar hospitals (n=486) without PCT measurements during the same period. The primary endpoint was antibiotic prescription in the first week of admission.ResultsAntibiotic prescription during the first 7 days was 26.8% in the PCT-group, 43.9% in the non-PCT group in the same hospital and 44.7% in the non-PCT group in other hospitals. Patients in the PCT-group had lower odds of receiving antibiotics in the first 7 days of admission (OR 0.33; 0.16 - 0.66 compared to the same hospital and OR 0.42; 95% CI 0.28 - 0.62 compared to the other hospitals). The proportion of patients receiving antibiotic prescription during the total admission was respectively 35.2%, 43.9% and 54.5%. The PCT-group had lower odds of receiving antibiotics during the total admission only when compared to the other hospitals (OR 0.23; 95%CI 0.08 - 0.63). There were no significant differences in other secondary endpoints, except for re-admission in the PCT-group versus the other hospitals group.InterpretationPCT-guided antibiotic prescription reduces antibiotic prescription rates in hospitalised patients with COVID-19, without major safety concerns.
| S-EPMC10132833 | biostudies-literature