Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial.
BACKGROUND
Urinary tract infections (UTIs) are common drivers of antibiotic use. The minimal effective duration of antibiotic therapy for UTIs is unknown, but any reduction is important to diminish selection pressure for antibiotic resistance, costs, and drug-related side-effects. The aim of this study was to investigate whether an algorithm based on procalcitonin (PCT) and quantitative pyuria reduces antibiotic exposure.


METHODS
From April 2012 to March 2014, we conducted a factorial design randomized controlled open-label trial. Immunocompetent adults with community-acquired non-catheter-related UTI were enrolled in the emergency department of a tertiary-care 600-bed hospital in northwestern Switzerland. Clinical presentation was used to guide initiation and duration of antibiotic therapy according to current guidelines (control group) or with a PCT-pyuria-based algorithm (PCT-pyuria group). The primary endpoint was overall antibiotic exposure within 90 days. Secondary endpoints included duration of the initial antibiotic therapy, persistent infection 7 days after end of therapy and 30 days after enrollment, recurrence and rehospitalizations within 90 days.


RESULTS
Overall, 394 patients were screened, 228 met predefined exclusion criteria, 30 declined to participate, and 11 were not eligible. Of these, 125 (76% women) were enrolled in the intention-to-treat (ITT) analysis and 96 patients with microbiologically confirmed UTI constituted the per protocol group; 84 of 125 (67%) patients had a febrile UTI, 28 (22%) had bacteremia, 5 (4%) died, and 3 (2%) were lost to follow-up. Overall antibiotic exposure within 90 days was shorter in the PCT-pyuria group than in the control group (median 7.0 [IQR, 5.0-14.0] vs. 10.0 [IQR, 7.0-16.0] days, P = 0.011) in the ITT analysis. Mortality, rates of persistent infections, recurrences, and rehospitalizations were not different.


CONCLUSIONS
A PCT-pyuria-based algorithm reduced antibiotic exposure by 30% when compared to current guidelines without apparent negative effects on clinical outcomes.
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. daniel.drozdov@ksa.ch.|Division of Infectious Diseases, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. daniel.drozdov@ksa.ch.
Daniel
D
Drozdov
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. steffyschwarz@gmail.com.
Stefanie
S
Schwarz
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. kutz.alexander@gmail.com.
Alexander
A
Kutz
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. eva.grolimund@ksa.ch.
Eva
E
Grolimund
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. rast.annachr@gmail.com.
Anna Christina
AC
Rast
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. deborah.steiner@ksa.ch.
Deborah
D
Steiner
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. katharina.regez@ksa.ch.
Katharina
K
Regez
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. ursula.schild@ksa.ch.
Ursula
U
Schild
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. merih.guglielmetti@ksa.ch.
Merih
M
Guglielmetti
Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. antoinette.conca@ksa.ch.
Antoinette
A
Conca
Department of Clinical Nursing Science, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. barbara.reutlinger@ksa.ch.
Barbara
B
Reutlinger
Department of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. cornelia.ottiger@ksa.ch.
Cornelia
C
Ottiger
Division of Nephrology, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. florian.buchkremer@ksa.ch.
Florian
F
Buchkremer
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. sebastian.haubitz@gmail.com.
Sebastian
S
Haubitz
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. claudineblum@yahoo.com.
Claudine
C
Blum
Department of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. andreas.huber@ksa.ch.
Andreas
A
Huber
Department of Emergency Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. ulrich.buergi@ksa.ch.
Ulrich
U
Buergi
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. schuetzph@gmail.com.
Philipp
P
Schuetz
Division of Nephrology, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. andreas.bock@ksa.ch.
Andreas
A
Bock
Division of Infectious Diseases, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. christophandreas.fux@ksa.ch.
Christoph Andreas
CA
Fux
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. happy.mueller@unibas.ch.
Beat
B
Mueller
Medical University Department, University of Basel, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. werner.albrich@kssg.ch.|Division of Infectious Diseases, Kantonsspital Aarau, Tellstrasse, Aarau, 5001, Switzerland. werner.albrich@kssg.ch.|Department of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, Rorschacherstrasse 95, St. Gallen, 9007, Switzerland. werner.albrich@kssg.ch.
Werner Christian
WC
Albrich
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D015415:Biomarkers / Q000032:analysis; D002116:Calcitonin / Q000032:analysis*; D015740:Calcitonin Gene-Related Peptide; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011498:Protein Precursors / Q000032:analysis*; D011776:Pyuria; D013557:Switzerland; D014552:Urinary Tract Infections / Q000188:drug therapy*
D000900:Anti-Bacterial Agents; D015415:Biomarkers; C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D015740:Calcitonin Gene-Related Peptide