FPIN's Clinical Inquiries

Procalcitonin-Guided Antibiotic Therapy for Acute Respiratory Infections


Am Fam Physician. 2016 Jul 1;94(1):53-58.

Clinical Question

Is the use of a procalcitonin-guided antibiotic therapy algorithm safe and effective for reducing antibiotic use in patients with acute respiratory infections?

Evidence-Based Answer

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.)

Evidence Summary

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).

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Table 1.

Recommendations for Procalcitonin-Guided Antibiotic Initiation in Adults with Acute Respiratory Infections

Procalcitonin level (μg per L)Recommendation

< 0.10

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

> 0.50

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.

Table 1.

Recommendations for Procalcitonin-Guided Antibiotic Initiation in Adults with Acute Respiratory Infections

Procalcitonin level (μg per L)Recommendation

< 0.10

Bacterial infection highly unlikely; strongly recommend against

Address correspondence to Carl Morris, MD, MPH, at morris.cg@ghc.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show 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.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group ( http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.



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