title: Excluding infection through procalcitonin testing improves outcomes of congestive heart failure patients presenting with acute respiratory symptoms: results from the randomized ProHOSP trial.
abstract: OBJECTIVE
  We sought to determine whether exclusion of infection and antibiotic stewardship with the infection biomarker procalcitonin improves outcomes in congestive heart failure (CHF) patients presenting to emergency departments with respiratory symptoms and suspicion of respiratory infection.
  
  
  METHODS
  We performed a secondary analysis of patients with a past medical history of CHF formerly included in a Swiss multicenter randomized-controlled trial. The trial compared antibiotic stewardship according to a procalcitonin algorithm or state-of-the-art guidelines (controls). The primary endpoint was a 30-day adverse outcome (death, intensive care unit admission); the secondary endpoints included a 30-day antibiotic exposure.
  
  
  RESULTS
  In the 110/233 analyzed patients (47.2%) with low initial procalcitonin (<0.25 μg/L), suggesting the absence of systemic bacterial infection, those randomized to procalcitonin guidance (n=50) had a significantly lower adverse outcome rate compared to controls (n=60): 4% vs. 20% (absolute difference -16.0%, 95% confidence interval (CI) -28.4% to -3.6%, P=0.01), and significantly reduced antibiotic exposure [days] (mean 3.7 ± 4.0 vs. 6.5 ± 4.4, difference -2.8 [95% CI, -4.4 to -1.2], P<0.01). When initial procalcitonin was ≥0.25 μg/L, procalcitonin-guided patients had significantly reduced antibiotic exposure due to early stop of therapy without any difference in adverse outcomes (25.8% vs. 24.6%, difference [95% CI] 1.2% [-14.5% to 16.9%, P=0.88]).
  
  
  CONCLUSIONS
  CHF patients presenting to the emergency department with respiratory symptoms and suspicion for respiratory infection had decreased antibiotic exposure and improved outcomes when procalcitonin measurement was used to exclude bacterial infection and guide antibiotic treatment. These data provide further evidence for the potential harmful effects of antibiotic / fluid treatment when used instead of diuretics and heart failure medication in clinically symptomatic CHF patients without underlying infection.
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Schuetz
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland. Electronic address: kutz.alexander@gmail.com.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kutz
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Eva
authors.initials: E
authors.lastname: Grolimund
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Haubitz
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Désirée
authors.initials: D
authors.lastname: Demann
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Alaadin
authors.initials: A
authors.lastname: Vögeli
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Fabienne
authors.initials: F
authors.lastname: Hitz
authors.affiliation: Department of Internal Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Switzerland.
authors.forename: Mirjam
authors.initials: M
authors.lastname: Christ-Crain
authors.affiliation: Department of Internal Medicine, Bürgerspital Solothurn, Switzerland.
authors.forename: Robert
authors.initials: R
authors.lastname: Thomann
authors.affiliation: Basel University Medical Clinic Liestal, Switzerland.
authors.forename: Claudine
authors.initials: C
authors.lastname: Falconnier
authors.affiliation: Department of Internal Medicine, Kantonsspital Münsterlingen, Switzerland.
authors.forename: Claus
authors.initials: C
authors.lastname: Hoess
authors.affiliation: Department of Internal Medicine, Kantonsspital Lucerne, Switzerland.
authors.forename: Christoph
authors.initials: C
authors.lastname: Henzen
authors.affiliation: Spencer-Fontayne Corporation, Jersey City, NJ, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Marlowe
authors.affiliation: Basel University Medical Clinic Liestal, Switzerland.
authors.forename: Werner
authors.initials: W
authors.lastname: Zimmerli
authors.affiliation: University Department of Medicine, Kantonsspital Aarau, Switzerland.
authors.forename: Beat
authors.initials: B
authors.lastname: Mueller
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D002116:Calcitonin / Q000097:blood; D015740:Calcitonin Gene-Related Peptide; D006333:Heart Failure / Q000097:blood / Q000188:drug therapy / Q000453:epidemiology; D011446:Prospective Studies; D011498:Protein Precursors / Q000097:blood; D012141:Respiratory Tract Infections / Q000097:blood / Q000188:drug therapy / Q000453:epidemiology; D013557:Switzerland / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D015415:Biomarkers; C000606589:CALCA protein, human; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide; D011498:Protein Precursors
keywords: Acute heart failure; Antibiotic stewardship; Antibiotic therapy; Differential diagnosis