Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in "real life": an international, multicenter poststudy survey (ProREAL).
BACKGROUND
In controlled studies, procalcitonin (PCT) has safely and effectively reduced antibiotic drug use for lower respiratory tract infections (LRTIs). However, controlled trial data may not reflect real life.


METHODS
We performed an observational quality surveillance in 14 centers in Switzerland, France, and the United States. Consecutive adults with LRTI presenting to emergency departments or outpatient offices were enrolled and registered on a website, which provided a previously published PCT algorithm for antibiotic guidance. The primary end point was duration of antibiotic therapy within 30 days.


RESULTS
Of 1759 patients, 86.4% had a final diagnosis of LRTI (community-acquired pneumonia, 53.7%; acute exacerbation of chronic obstructive pulmonary disease, 17.1%; and bronchitis, 14.4%). Algorithm compliance overall was 68.2%, with differences between diagnoses (bronchitis, 81.0%; AECOPD, 70.1%; and community-acquired pneumonia, 63.7%; P < .001), outpatients (86.1%) and inpatients (65.9%) (P < .001), algorithm-experienced (82.5%) and algorithm-naive (60.1%) centers (P < .001), and countries (Switzerland, 75.8%; France, 73.5%; and the United States, 33.5%; P < .001). After multivariate adjustment, antibiotic therapy duration was significantly shorter if the PCT algorithm was followed compared with when it was overruled (5.9 vs 7.4 days; difference, -1.51 days; 95% CI, -2.04 to -0.98; P < .001). No increase was noted in the risk of the combined adverse outcome end point within 30 days of follow-up when the PCT algorithm was followed regarding withholding antibiotics on hospital admission (adjusted odds ratio, 0.83; 95% CI, 0.44 to 1.55; P = .56) and regarding early cessation of antibiotics (adjusted odds ratio, 0.61; 95% CI, 0.36 to 1.04; P = .07).


CONCLUSIONS
This study validates previous results from controlled trials in real-life conditions and demonstrates that following a PCT algorithm effectively reduces antibiotic use without increasing the risk of complications. Preexisting differences in antibiotic prescribing affect compliance with antibiotic stewardship efforts.


BACKGROUND
isrctn.org Identifier: ISRCTN40854211.
Medical University Department, Kantonsspital Aarau, Aarau, Switzerland.
Werner C
WC
Albrich
Frank
F
Dusemund
Birgit
B
Bucher
Stefan
S
Meyer
Robert
R
Thomann
Felix
F
Kühn
Stefano
S
Bassetti
Martin
M
Sprenger
Esther
E
Bachli
Thomas
T
Sigrist
Martin
M
Schwietert
Devendra
D
Amin
Pierre
P
Hausfater
Eric
E
Carre
Jacques
J
Gaillat
Philipp
P
Schuetz
Katharina
K
Regez
Rita
R
Bossart
Ursula
U
Schild
Beat
B
Mueller
D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002116:Calcitonin / Q000627:therapeutic use*; D015740:Calcitonin Gene-Related Peptide; D018849:Controlled Clinical Trials as Topic; D004359:Drug Therapy, Combination; D005260:Female; D005602:France; D006801:Humans; D008297:Male; D008875:Middle Aged; D011498:Protein Precursors / Q000627:therapeutic use*; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000188:drug therapy*; D013557:Switzerland; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide