Procalcitonin-guided antibiotic therapy algorithms for different types of acute respiratory infections based on previous trials

Abstract

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.

Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimized clinical use

“…Results were consistent for the different clinical settings requiring ICU admission) cut-offs of 0.5 μg/L were mainly used [24]. Similarly, for antibiotic discontinuation a PCT decrease below 0.25 μg/L or 0.5 μg/L were used for mild/ moderate or severe illness, respectively, or when PCT showed a drop by ≥80% from the peak [8].…”

“…Levels of PCT can help to discriminate bacterial from viral disease and have been shown to lead to decreased rates of antibiotic prescriptions safely and early discontinuation of therapy [5][6][7]. PCT expression is upregulated in epithelial cells which encounter bacterial pathogens and thus provides information about the risk for bacterial infection upon initial patient assessment [8]. Conversely, PCT expression is down-regulated in patients with viral infections [9].…”

“…Still, one barrier to the more wide-spread routine use of PCT is the lack of clarity regarding the clinical algorithm because previous trials all used somewhat different PCT protocols depending on clinical setting (primary care settings, emergency departments [ED] and intensive care units [ICU]) and type of infection e.g. community-acquired pneumonia (CAP), bronchitis, chronic obstructive pulmonary disease (COPD) or asthma exacerbation, sepsis and post-operative sepsis [8]. Algorithm recommendations differed in regard to timing of follow-up PCT measurement and specific treatment recommendation.…”

Biomarkers of Infection: Are They Useful in the ICU?

“…2 provides practical guides for a rational use of PCT in high-risk settings in conjunction with the clinical assessment including interpretation of PCT and recommendations for antibiotic use. 21,57 To optimize antibiotic stewardship, implementation of supplemental educational programs would be useful. In the interventional noninferiority proACT trial, no reduction of antibiotic prescription or treatment duration among patients with suspected lower respiratory tract infection in the emergency department could be observed.…”

Monitoring Antibiotics and Inflammatory Markers in Human Blood: Impact in Choice of Antibiotic Therapy and Used Methods

“…To evaluate the efficacy of antibiotic therapy, it is necessary to concentrate on the main indicators-the concentration of the administered antibiotic (in blood, serum, plasma, urine, cerebrospinal fluid, if necessary) [70]-as well as the content of inflammatory markers (C-reactive protein as an acute phase protein and procalcitonin as an express marker of bacterial infections) [71][72][73].…”