title: Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance.
abstract: Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 μg/L and +31 % if PCT > 0.25 μg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 μg/L and +13 % if PCT > 0.25 μg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 μg/L and +19 % if PCT > 0.25 μg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.
authors.affiliation: Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland.
authors.forename: F
authors.initials: F
authors.lastname: Dusemund
authors.forename: B
authors.initials: B
authors.lastname: Bucher
authors.forename: S
authors.initials: S
authors.lastname: Meyer
authors.forename: R
authors.initials: R
authors.lastname: Thomann
authors.forename: F
authors.initials: F
authors.lastname: Kühn
authors.forename: S
authors.initials: S
authors.lastname: Bassetti
authors.forename: M
authors.initials: M
authors.lastname: Sprenger
authors.forename: E
authors.initials: E
authors.lastname: Baechli
authors.forename: T
authors.initials: T
authors.lastname: Sigrist
authors.forename: M
authors.initials: M
authors.lastname: Schwietert
authors.forename: D
authors.initials: D
authors.lastname: Amin
authors.forename: P
authors.initials: P
authors.lastname: Hausfater
authors.forename: E
authors.initials: E
authors.lastname: Carre
authors.forename: P
authors.initials: P
authors.lastname: Schuetz
authors.forename: J
authors.initials: J
authors.lastname: Gaillat
authors.forename: K
authors.initials: K
authors.lastname: Regez
authors.forename: R
authors.initials: R
authors.lastname: Bossart
authors.forename: U
authors.initials: U
authors.lastname: Schild
authors.forename: B
authors.initials: B
authors.lastname: Müller
authors.forename: W C
authors.initials: WC
authors.lastname: Albrich
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001424:Bacterial Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000473:pathology; D002116:Calcitonin / Q000097:blood*; D015740:Calcitonin Gene-Related Peptide; D024881:Drug Resistance, Bacterial; D004363:Drug Utilization / Q000592:standards*; D005602:France; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D011446:Prospective Studies; D011498:Protein Precursors / Q000097:blood*; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology*
chemical_list: D000900:Anti-Bacterial Agents; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide