Procalcitonin-guided antibiotic treatment in patients with acute respiratory infections reduces antibiotic exposure and side effects while improving mortality rates, according to the results of a study published in Lancet Infectious Diseases.
Procalcitonin is produced by human epithelial cells reacting to bacterial infections, but it is downregulated during viral infections. In February 2017, the US Food and Drug Administration approved procalcitonin as a surrogate marker of bacterial infection and as a guide to antibiotic prescribing in conjunction with other traditional clinical and diagnostic measures in acute respiratory infections.
Philipp Schuetz, MD, professor at Medical University, Kantonsspital Aarau, Switzerland, and colleagues conducted a systematic literature search. They pooled data from trials in which patients were randomly assigned to a control group or received antibiotics for respiratory infections (including pneumonia and exacerbations of bronchitis and chronic obstructive pulmonary disease) based on procalcitonin concentrations. Primary end points were 30-day mortality and setting-specific treatment failure. Secondary end points included antibiotic use, length of stay, and antibiotic adverse effects.
The investigators collected data on 6708 patients from 26 trials held in 12 countries. The mortality rate at 30 days was significantly lower in the procalcitonin group than in the control group (9% vs 10%, respectively; adjusted odds ratio, 0.83; 95% CI, 0.70-0.99; P =.037). The improvement in mortality was seen across subgroups and settings. Use of procalcitonin to guide antibiotic decisions resulted in a 2.4-day reduction in antibiotic exposure (5.7 vs 8.1 days; 95% CI, –2.71 to –2.15; P <.0001) and a reduction in antibiotic-associated adverse effects (16% vs 22% adjusted odds ratio, 0.68; 95% CI, 0.57-0.82; P <.0001).
Study limitations included variation in adherence to the procalcitonin algorithm that ranged from 44% to 100%; however, a sensitivity analysis found similar effects in trials with low and high adherence. Another limitation was the inclusion of only adults with normal immune response who had acute respiratory infections. A third limitation was the heterogeneous nature of the patient population with regard to clinical setting and type of respiratory infection.
Nevertheless, the authors suggested that widespread implementation of procalcitonin protocols in patients with acute respiratory infections has the potential to reduce the threat of increasing antibiotic multiresistance and improve antibiotic management, resulting in better clinical outcomes.
Schuetz P, Wirz Y, Sager R, et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infect Dis. 2018;18:95-107.