FPIN's Clinical Inquiries
Procalcitonin-Guided Antibiotic Therapy for Acute Respiratory Infections
Am Fam Physician. 2016 Jul 1;94(1):53-58.
Is the use of a procalcitonin-guided antibiotic therapy algorithm safe and effective for reducing antibiotic use in patients with acute respiratory infections?
A procalcitonin-guided antibiotic therapy algorithm should be used to decrease antibiotic use in adults with acute respiratory infections. (Strength of Recommendation [SOR]: A, based on a meta-analysis of multiple randomized controlled trials [RCTs].) The use of a procalcitonin-guided therapy algorithm reduces antibiotic use by 3.47 days without increasing morbidity or mortality in adults with acute respiratory infections. In the primary care setting, the use of procalcitonin-guided therapy algorithms decreases the rate of antibiotic prescription by 72% without affecting the risk of treatment failure. In children with lower respiratory tract infections, procalcitonin guidance should be used to reduce the duration of antibiotic therapy. (SOR: B, based on a single RCT.)
A Cochrane review and meta-analysis of 14 RCTs in primary care, emergency department, and intensive care unit settings included a total of 4,221 patients.1 In each trial, researchers randomized adults presenting with acute respiratory infections to procalcitonin-guided antibiotic therapy or standard care. All studies used a procalcitonin algorithm to guide antibiotic initiation (Table 1), and some also used the algorithm to guide discontinuation. Patients in the procalcitonin group received 3.47 fewer days of antibiotic treatment (95% confidence interval [CI], −3.78 to −3.17), with no difference in 30-day mortality (odds ratio [OR] = 0.94; 95% CI, 0.71 to 1.23) or treatment failure (OR = 0.82; 95% CI, 0.67 to 1.01).
Recommendations for Procalcitonin-Guided Antibiotic Initiation in Adults with Acute Respiratory Infections
|Procalcitonin level (μg per L)||Recommendation|
Bacterial infection highly unlikely; strongly recommend against antibiotics
0.10 to < 0.25
Bacterial infection unlikely; recommend against antibiotics
0.25 to 0.50
Bacterial infection likely; recommend antibiotics
Bacterial infection very likely; strongly recommend antibiotics
note: Algorithm for discontinuation of antibiotic therapy was more variable, with many studies recommending discontinuation when procalcitonin levels were decreased by 80% to 90% from baseline level or were < 0.25 μg per L.
Recommendations for Procalcitonin-Guided Antibiotic Initiation in Adults with Acute Respiratory
REFERENCESshow all references
1. Schuetz P, Müller B, Christ-Crain M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2012;(9):CD007498....
2. Briel M, Schuetz P, Mueller B, et al. Procalcitonin-guided antibiotic use vs a standard approach for acute respiratory tract infections in primary care. Arch Intern Med. 2008;168(18):2000–2007.
3. Burkhardt O, Ewig S, Haagen U, et al. Procalcitonin guidance and reduction of antibiotic use in acute respiratory tract infection. Eur Respir J. 2010;36(3):601–607.
4. Baer G, Baumann P, Buettcher M, et al. Procalcitonin guidance to reduce antibiotic treatment of lower respiratory tract infection in children and adolescents (Pro-PAED): a randomized controlled trial. PLoS One. 2013;8(8):e68419.
5. Soni NJ, Samson DJ, Galaydick JL, Vats V, Pitrak DL, Aronson N. Procalcitonin-guided antibiotic therapy: executive summary. Comparative Effectiveness Review No. 78. Rockville, Md.: Agency for Healthcare Research and Quality; 2012. AHRQ publication no. 12(13)-EHC 124-EF.
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