title: Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial.
abstract: BACKGROUND
  In previous smaller trials, a procalcitonin (PCT) algorithm reduced antibiotic use in patients with lower respiratory tract infections (LRTIs).
  
  
  OBJECTIVE
  To examine whether a PCT algorithm can reduce antibiotic exposure without increasing the risk for serious adverse outcomes.
  
  
  METHODS
  A multicenter, noninferiority, randomized controlled trial in emergency departments of 6 tertiary care hospitals in Switzerland with an open intervention of 1359 patients with mostly severe LRTIs randomized between October 2006 and March 2008.
  
  
  METHODS
  Patients were randomized to administration of antibiotics based on a PCT algorithm with predefined cutoff ranges for initiating or stopping antibiotics (PCT group) or according to standard guidelines (control group). Serum PCT was measured locally in each hospital and instructions were Web-based.
  
  
  METHODS
  Noninferiority of the composite adverse outcomes of death, intensive care unit admission, disease-specific complications, or recurrent infection requiring antibiotic treatment within 30 days, with a predefined noninferiority boundary of 7.5%; and antibiotic exposure and adverse effects from antibiotics.
  
  
  RESULTS
  The rate of overall adverse outcomes was similar in the PCT and control groups (15.4% [n = 103] vs 18.9% [n = 130]; difference, -3.5%; 95% CI, -7.6% to 0.4%). The mean duration of antibiotics exposure in the PCT vs control groups was lower in all patients (5.7 vs 8.7 days; relative change, -34.8%; 95% CI, -40.3% to -28.7%) and in the subgroups of patients with community-acquired pneumonia (n = 925, 7.2 vs 10.7 days; -32.4%; 95% CI, -37.6% to -26.9%), exacerbation of chronic obstructive pulmonary disease (n = 228, 2.5 vs 5.1 days; -50.4%; 95% CI, -64.0% to -34.0%), and acute bronchitis (n = 151, 1.0 vs 2.8 days; -65.0%; 95% CI, -84.7% to -37.5%). Antibiotic-associated adverse effects were less frequent in the PCT group (19.8% [n = 133] vs 28.1% [n = 193]; difference, -8.2%; 95% CI, -12.7% to -3.7%).
  
  
  CONCLUSIONS
  In patients with LRTIs, a strategy of PCT guidance compared with standard guidelines resulted in similar rates of adverse outcomes, as well as lower rates of antibiotic exposure and antibiotic-associated adverse effects.
  
  
  BACKGROUND
  isrctn.org Identifier: ISRCTN95122877.
authors.affiliation: Department of Internal Medicine, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Schuetz
authors.forename: Mirjam
authors.initials: M
authors.lastname: Christ-Crain
authors.forename: Robert
authors.initials: R
authors.lastname: Thomann
authors.forename: Claudine
authors.initials: C
authors.lastname: Falconnier
authors.forename: Marcel
authors.initials: M
authors.lastname: Wolbers
authors.forename: Isabelle
authors.initials: I
authors.lastname: Widmer
authors.forename: Stefanie
authors.initials: S
authors.lastname: Neidert
authors.forename: Thomas
authors.initials: T
authors.lastname: Fricker
authors.forename: Claudine
authors.initials: C
authors.lastname: Blum
authors.forename: Ursula
authors.initials: U
authors.lastname: Schild
authors.forename: Katharina
authors.initials: K
authors.lastname: Regez
authors.forename: Ronald
authors.initials: R
authors.lastname: Schoenenberger
authors.forename: Christoph
authors.initials: C
authors.lastname: Henzen
authors.forename: Thomas
authors.initials: T
authors.lastname: Bregenzer
authors.forename: Claus
authors.initials: C
authors.lastname: Hoess
authors.forename: Martin
authors.initials: M
authors.lastname: Krause
authors.forename: Heiner C
authors.initials: HC
authors.lastname: Bucher
authors.forename: Werner
authors.initials: W
authors.lastname: Zimmerli
authors.forename: Beat
authors.initials: B
authors.lastname: Mueller
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002116:Calcitonin / Q000097:blood*; D015740:Calcitonin Gene-Related Peptide; D003661:Decision Support Techniques; D004363:Drug Utilization; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011498:Protein Precursors / Q000097:blood*; D012141:Respiratory Tract Infections / Q000097:blood* / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide