There was no difference between procalcitonin-guided care and guideline-based serial clinical assessment for reducing antibiotic exposure in patients with community-acquired pneumonia admitted to the emergency department (ED), according to study results published in the Annals of Emergency Medicine.
Researchers enrolled patients from 12 different French hospitals admitted to the ED with community-acquired pneumonia. Based on the Infectious Diseases Society of America/American Thoracic Society guidelines, the investigators randomly assigned patients to either a procalcitonin-guided program (n=142) or guideline-based serial clinical assessment (n=143). Antibiotic duration comprised the primary outcome. Secondary outcomes were the rate of antibiotic duration ≤5 days, as well as clinical success and combined serious adverse outcomes at 30 days.
In the procalcitonin-guided care group, patients with procalcitonin levels <0.1 µg/L were strongly recommended to not receive antibiotics and not recommended to receive antibiotics if their levels were ≤0.25 µg/L. Antibiotics were strongly recommended in patients who presented to the ED with procalcitonin levels of >0.5 µg/L and recommended if their levels were >0.25 µg/L.
In the guideline-based serial clinical assessment group, patients were assessed approximately 6 to 24 hours after being randomly assigned to either continuation or discontinuation of antibiotics in the ED. Determination of continuation or discontinuation of antibiotic therapy was made based on clinical findings, chest radiograph, and laboratory tests performed in the ED.
Median age of the overall cohort was 67 years (range, 18-93 years), and 40% presented with Pneumonia Severity Index class IV or V. In the clinical assessment group and procalcitonin group, the initial median procalcitonin levels were 0.83 µg/L (interquartile range [IQR], 0.14-3.18 µg/L [range, 0.03-45.82 µg/L]) and 0.71 µg/L (IQR, 0.17-3.06 µg/L [range, 0.04-37.69 µg/L]), respectively.
No difference was observed between the clinical assessment and procalcitonin-guided groups in terms of the median duration of antibiotic therapy (9 vs 10 days, respectively; P =.21). At 30 days, the clinical cure rate was 92% in each group and there was no difference between the clinical assessment and procalcitonin-guided care group in terms of serious adverse outcome rates (15% vs 20%; difference, 5%; 95% CI, -4% to 14%).
Study limitations included the short follow-up period and the lack of a usual care comparator group.
“Because procalcitonin assessments add time and cost to patient care,” the researchers noted, “these findings support strategies to promote better provider understanding and application of clinical guidelines for management of patients with community-acquired pneumonia.”
Montassier E, Javaudin F, Moustafa F, et al. Guideline-based clinical assessment versus procalcitonin-guided antibiotic use in pneumonia: a pragmatic randomized trial [published online April 11, 2019]. Ann Emerg Med. doi:10.1016/j.annemergmed.2019.02.025