Using procalcitonin to guide antibiotics for pneumonia - PulmCCM
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Apr 242013
 
Use of Procalcitonin to Reduce Unnecessary Antibiotics

by Blair Westerly, MD

Acute respiratory tract infections have a wide range of disease severity and the use of antibiotics for self-limited infections contributes to antibiotic overuse and antimicrobial resistance, though we have all probably been guilty of it a time or two when we just weren’t sure of whether our patient “only” has a virus. Procalcitonin is released in response to bacterial toxins and inflammatory mediators and can help clinicians differentiate which patients may benefit from antibiotic therapy. What are the outcomes when procalcitonin is used to guide therapy?  Schuetz, Briel and Mueller reviewed this question in a recent issue of JAMA.

What They Did

Systematic review of 14 randomized trials and more than 4,000 patients with respiratory tract infections where therapy was directed with or without procalcitonin levels.

Primary outcomes were 30-day all cause mortality and treatment failure within 30 days.

 

What They Found
  • No increase in all-cause mortality for any type of respiratory tract infection or clinical setting when using procalcitonin testing.
  • There was less treatment failure in the emergency department (OR 0.76, 95% CI 0.61-0.95) and in patients with community acquired pneumonia (OR 0.77, 95% CI 0.62-0.96) when using procalcitonin levels.
  • Procalcitonin guidance resulted in lower antibiotic exposure (median 4 d vs 8 d), especially for exacerbations of COPD and bronchitis.
  • Shorter antibiotic courses were seen for patients when treatment was guided by procalcitonin in the emergency department and the ICU, and in patients with a diagnosis of community acquired pneumonia.

 

takeawayClinical Takeaway: Using procalcitonin levels to guide therapy does not seem to be associated with any harm and may benefit patients by decreasing antibiotic exposure, decreasing the duration of antibiotic treatment, and preventing the development of resistant microbes. Sounds like a win-win-win, doesn’t it?  The one major caveat that stands out is the relative under-representation of ICU patients in the body of randomized trial evidence. We may need more randomized trials evaluating procalcitonin guidance in the United States, but the world seems to be one step ahead of us. If health expenditures can be reduced by instituting procalcitonin algorithms (test costs about $25-30), maybe it's time we get on board with our European colleagues and allow procalcitonin to help us help our patients.

Procalcitonin to diagnose infections (PulmCCM Review)

Clinical outcomes associated with procalcitonin algorithms to guide antibiotic therapy respiratory tract infections. Schuetz et al. JAMA 2013; vol 309(7): 717-718.

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Using procalcitonin to guide antibiotics for pneumonia