Procalcitonin‐guided protocol decreased the antibiotic use in paediatric patients with severe bronchiolitis

Abstract

Bronchiolitis is an acute inflammatory injury of the bronchioles, which is usually caused by a viral infection. It is the most common cause of lower respiratory tract infection in the first year of life. 1-3 Respiratory syncytial virus is the most common causative agent. 4,5 An important complication is the concurrence of an invasive bacterial infection and these include pneumonia, meningitis, sepsis and urinary tract infections. Invasive bacterial infections are a major cause of morbidity and mortality, with a considerable prevalence in infants who require paediatric intensive care unit (PICU) admission and mechanical ventilation. 6-8 One of the main challenges is making a differential diagnosis between invasive bacterial infections and isolated viral infections, especially in younger patients with bronchiolitis. Consequently, it is common to use antibiotics for severe cases of bronchiolitis. However, often this is not necessary, because in most cases it is a viral illness. 9,10

How to reduce the use of antibiotics in infant bronchiolitis?

“…Since the reliable microbe‐specific diagnosis of bacterial lower respiratory infection is seldom possible, a rationale way is to apply algorithms based on monitoring of non‐specific inflammatory markers such as serum PCT or CRP to guide the prescription of antibiotics. Alejandre et al publish in the current issue of the journal their results on 706 Spanish infants treated in the PICU for bronchiolitis at the median age of 47 days during the surveillance period of 8 years. The start of antibiotics was refrained, if not necessary to treat an invasive bacterial infection as long as PCT stayed at the level of <1.0 ng/mL (and CRP < 70 mg/L), and correspondingly, antibiotics could be withdrawn if going‐on when PCT fell back to <1.0 ng/mL.…”

“…After implementation of these PCT‐based guides, the use of antibiotics decreased from 89% to 72% of bronchiolitis patients, but the use was still much higher than for example the figures of 34%, 19% and 43% in infants treated for bronchiolitis in the PICU of our hospital during three 5‐year surveillance periods in 2000‐2015 . Antibiotic stewardship and withdrawal decisions increased from 22.4% to 36.4% without any adverse outcomes caused by these decisions.…”

“…Antibiotic stewardship and withdrawal decisions increased from 22.4% to 36.4% without any adverse outcomes caused by these decisions. The mean length of antibiotic courses decreased from 8.7 to 5.1 days . No doubt, such decrease of more than three days is clinically significant lessening both immediate and later harmful effects of antibiotics.…”

“…No doubt, such decrease of more than three days is clinically significant lessening both immediate and later harmful effects of antibiotics. However, the lengths of hospital and PICU stays were similar before and after implementation of the guides, in median 12 vs 13 days in the hospital and 6 vs 6 days in the PICU, and so, the programme was not necessarily cost saving.…”

“…Alejandre et al used historical controls, since they compared 340 cases treated before the implementation of the PCT‐based guides in 2010‐2013 to 366 cases treated after the implementation in 2014‐2017. The possible changes in bronchiolitis treatment during the 8‐year surveillance period were not taken into account in the analyses.…”