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ABSTRACT
Introduction: Although evidence indicates that use of procalcitonin to guide antibiotic decisions for the treatment of acute respiratory infections (ARI) decreases antibiotic consumption and improves clinical outcomes, algorithms used within studies had differences in PCT cut-off points and frequency of testing. We therefore analyzed studies evaluating procalcitonin-guided antibiotic therapy and propose consensus algorithms for different respiratory infection types.
Areas covered: We systematically searched randomized-controlled trials (search strategy updated on February 2018) on procalcitonin-guided antibiotic therapy of ARI in adults using a pre-specified Cochrane protocol and analyzed algorithms from 32 trials that included 10,285 patients treated in primary care settings, emergency departments (ED), and intensive care units (ICU). We derived consensus algorithms for use of procalcitonin by the type of ARI including community-acquired pneumonia, bronchitis, chronic obstructive pulmonary disease or asthma exacerbation, sepsis, and post-operative sepsis due to respiratory infection. Consensus algorithm recommendations differ with regard to timing of treatment (i.e. timing of initiation in low-risk patients or discontinuation in high-risk patients) and procalcitonin cut-off points for the recommendation/strong recommendation to discontinue antibiotics (≤ 0.25/≤ 0.1 µg/L in ED and inpatients, ≤ 0.5/≤ 0.25 µg/L in ICU patients, and reduction by ≥ 80% from peak levels in sepsis patients).
Expert commentary: Our proposed algorithms may facilitate safe and efficient implementation of procalcitonin-guided antibiotic protocols in diverse healthcare settings. Still, the decision about initiation and cessation of antibiotic treatment remains a clinical decision based on the patient assessment and the severity of illness and use of procalcitonin should not delay empirical treatment in high risk situations.
Acknowledgments
We thank Yannick Wirz, MD and Ramon Sager, MD of the Kantonsspital Aarau, Aarau, Switzerland for their assistance with the assessment of the trials included in this analysis. We also thank Prasad Kulkarni, PhD, CMPP of Asclepius Medical Communications LLC, Ridgewood, NJ, USA for editorial assistance, which was funded by bioMérieux.
Declaration of interest
No commercial sponsor had any involvement in design and conduct of this study, namely collection, management, analysis, and interpretation of the data; and preparation, decision to submit, review, or approval of the manuscript. P Schuetz, M Christ-Crain and Mueller received support from Thermo-Fisher and bioMérieux to attend meetings and fulfilled speaking engagements. B Mueller has served as a consultant and received research support. PS also received research support from other diagnostic companies including ROCHE and Abbott. D Stolz and M Tamm received research support from Thermo-Fisher. T Welte and S Schroeder received lecture fees and research support from Thermo-Fisher CE Luyt received lecture fees from Brahms and Merck Sharp & Dohme-Chibret. M Wolff received consulting and lectures fees from Merck Sharp & Dohme-Chibret, Janssen–Cilag, Gilead, Astellas, Sanofi and Thermo-Fisher. Y Shehabi received unrestricted research grants from Thermo-fisher, bioMérieux, Orion Pharma and Pfizer. J-U Jensen declares that he was invited to the European Respiratory Society meeting 2016 by Roche Pharmaceuticals. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Supplementary material
Supplementary data can be accessed here.
Reviewer disclosures
A reviewer on this manuscript has disclosed receipt of honoraria and research report from bioMerieux during the past 5 years, and states this will not influence their review.