October 23, 2017
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Procalcitonin-guided treatment cuts mortality risk in respiratory patients

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Researchers said they found “significant and relevant improvements in clinical outcomes” when procalcitonin was used to guide antibiotic treatment in patients with acute respiratory infections.

Specifically, a meta-analysis of dozens of trials in 12 countries showed that procalcitonin-guided treatment reduced antibiotic exposure and side effects and improved survival in these patients.

In February, the FDA approved the first test to use procalcitonin — a biomarker indicating the body’s response to bacterial infections — as a guide for antibiotic therapy in patients with acute respiratory infections.

“Acute respiratory tract illnesses are one of the leading causes of adult hospital admissions and death worldwide, and are associated with antibiotic overuse,” Philipp Schuetz, MD, of Kantonsspital Aarau hospital and the University of Basel in Switzerland, and colleagues wrote in The Lancet Infectious Diseases. “Although more than 40% of respiratory infections have a viral cause, imprecise bacterial diagnostics and provider concerns about co-infection prompt antibiotic prescription in most cases.”

Schuetz and colleagues searched the literature for trials in which patients with respiratory infections were randomly assigned to receive antibiotics based on procalcitonin concentrations or to control groups. Their meta-analysis included data from 6,708 patients from 26 eligible trials in Australia, Belgium, Brazil, China, Denmark, France, Germany, Italy, the Netherlands, the United States, Serbia and Switzerland.

According to their analysis, mortality at 30 days was significantly lower in patients who received procalcitonin-guided antibiotic treatment compared with controls — 286 in 3,336 (9%) vs. 336 in 3,372 (10%), with an adjusted OR of 0.83 (95 CI, 0.70 to 0.99; P = .037). Procalcitonin-guided treatment also was associated with a 2.4-day reduction in antibiotic exposure and a 32% reduced likelihood of antibiotic-related side effects, Schuetz and colleagues reported.

In a related editorial, Patricia S. Fontela, MD, PhD, and Jesse Papenburg, MD, both of McGill University Health Centre in Montreal, said the lower 30-day mortality rate in the procalcitonin-guided group “could be explained by a reduction in antibiotic-related side effects, including Clostridium difficile colitis.”

Fontela and Papenburg called procalcitonin-guided antibiotic treatment “imperfect, yet effective” and said there are challenges to its widespread use. They said procalcitonin will not solve the problem of antibiotic overuse in patients with acute respiratory tract infections but that the strategy is still “worthwhile.”

“Although procalcitonin provides important information about a potential bacterial cause and the resolution of bacterial processes, the clinical reasoning behind antibiotic-related decisions is also strongly influenced by patient and disease characteristics, such as severity, and physicians' previous experiences, which can easily override any algorithm recommendation,” they wrote.

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“Nevertheless, we should not be looking for perfection when dealing with antibiotic overuse, but for strategies that can mitigate the global bacterial resistance problem. Thus, if procalcitonin can safely decrease unnecessary antibiotic use in different settings, even if imperfectly, it is already worthwhile.” – by Gerard Gallagher

Disclosures: Please see the study and editorial for all authors’ relevant financial disclosures.