Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial.
BACKGROUND
Lower respiratory tract infections are often treated with antibiotics without evidence of clinically relevant bacterial disease. Serum calcitonin precursor concentrations, including procalcitonin, are raised in bacterial infections. We aimed to assess a procalcitonin-based therapeutic strategy to reduce antibiotic use in lower respiratory tract infections with a new rapid and sensitive assay.


METHODS
243 patients admitted with suspected lower respiratory tract infections were randomly assigned standard care (standard group; n=119) or procalcitonin-guided treatment (procalcitonin group; n=124). On the basis of serum procalcitonin concentrations, use of antibiotics was more or less discouraged (<0.1 microg/L or <0.25 microg/L) or encouraged (> or =0.5 microg/L or > or =0.25 microg/L), respectively. Re-evaluation was possible after 6-24 h in both groups. Primary endpoint was use of antibiotics and analysis was by intention to treat.


RESULTS
Final diagnoses were pneumonia (n=87; 36%), acute exacerbation of chronic obstructive pulmonary disease (60; 25%), acute bronchitis (59; 24%), asthma (13; 5%), and other respiratory affections (24; 10%). Serological evidence of viral infection was recorded in 141 of 175 tested patients (81%). Bacterial cultures were positive from sputum in 51 (21%) and from blood in 16 (7%). In the procalcitonin group, the adjusted relative risk of antibiotic exposure was 0.49 (95% CI 0.44-0.55; p<0.0001) compared with the standard group. Antibiotic use was significantly reduced in all diagnostic subgroups. Clinical and laboratory outcome was similar in both groups and favourable in 235 (97%).


CONCLUSIONS
Procalcitonin guidance substantially reduced antibiotic use in lower respiratory tract infections. Withholding antimicrobial treatment did not compromise outcome. In view of the current overuse of antimicrobial therapy in often self-limiting acute respiratory tract infections, treatment based on procalcitonin measurement could have important clinical and financial implications.
Division of Pneumology, University Hospitals, Petersgraben 4, CH-4031 Basel, Switzerland.
Mirjam
M
Christ-Crain
Daiana
D
Jaccard-Stolz
Roland
R
Bingisser
Mikael M
MM
Gencay
Peter R
PR
Huber
Michael
M
Tamm
Beat
B
Müller
D000208:Acute Disease; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001424:Bacterial Infections / Q000097:blood / Q000188:drug therapy; D001991:Bronchitis / Q000097:blood / Q000188:drug therapy; D002116:Calcitonin / Q000097:blood*; D015740:Calcitonin Gene-Related Peptide; D017723:Drug Utilization Review; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000097:blood / Q000188:drug therapy; D011498:Protein Precursors / Q000097:blood*; D029424:Pulmonary Disease, Chronic Obstructive / Q000097:blood / Q000188:drug therapy; D012141:Respiratory Tract Infections / Q000097:blood* / Q000188:drug therapy* / Q000382:microbiology; D016037:Single-Blind Method; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide