title: Higher diagnostic accuracy and cost-effectiveness using procalcitonin in the treatment of emergency medicine patients with fever (The HiTEMP study): a multicenter randomized study.
abstract: BACKGROUND
  Fever is a common symptom in the emergency department(ED). Fever can be caused by bacterial infections, which are treated with antibiotics. Often, bacterial infections cannot be ruled out in the ED using standard diagnostics, and empiric antibiotic treatment is started. Procalcitonin(PCT) is a biomarker for bacterial infections, but its role in an undifferentiated ED population remains unclear. We hypothesize that PCT-guided therapy may reduce antibiotics prescription in undifferentiated febrile ED patients. The primary objectives of this study are to determine a) the efficacy, b) the safety of PCT-guided therapy, and c) the accuracy of the biomarker PCT for bacterial infections. The secondary objective is to study the cost-effectiveness of PCT-guided therapy.
  
  
  METHODS
  This is a multicenter noninferiority randomized controlled trial. All adult ED patients with fever(≥38.2 °C) are randomized between standard care with and without the addition of a PCT level, after written informed consent. a) For efficacy, the reduction of patients receiving antibiotics is calculated, using a superiority analysis: differences between the PCT-guided group and control group are assessed using a Fisher's exact test, and a multivariable logistic regression analysis to account for the effects of demographic and medical variables on the percentage of febrile patients receiving antibiotics. b) Safety consists of a composite endpoint, defined as mortality, intensive care admission and ED return visit within 14 days. Noninferiority of PCT will be tested using a one-sided 95 % confidence interval for the difference in the composite safety endpoint between the PCT-guided and control groups using a noninferiority margin of 7.5 %. c) Accuracy of PCT and CRP for the diagnosis of bacterial infections will be reported, using the sensitivity, specificity, and the area under the receiver-operating-characteristic curve in the definitive diagnosis of bacterial infections. The sample size is 550 patients, which was calculated using a power analysis for all primary objectives. Enrollment of patients started in August 2014 and will last 2 years.
  
  
  CONCLUSIONS
  PCT may offer a more tailor-made treatment to the individual ED patient with fever. Prospective costs analyses will reveal the economic consequences of implementing PCT-guided therapy in the ED.
  NTR4949.
authors.affiliation: Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands. y.vanderdoes@erasmusmc.nl.
authors.forename: Yuri
authors.initials: Y
authors.lastname: van der Does
authors.affiliation: Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Maarten
authors.initials: M
authors.lastname: Limper
authors.affiliation: Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.|Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Stephanie C E
authors.initials: SC
authors.lastname: Schuit
authors.affiliation: Institute for Medical Technology Assessment (iMTA), Erasmus University, Rotterdam, The Netherlands.|Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Marten J
authors.initials: MJ
authors.lastname: Poley
authors.affiliation: Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Joost
authors.initials: J
authors.lastname: van Rosmalen
authors.affiliation: Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Christian
authors.initials: C
authors.lastname: Ramakers
authors.affiliation: Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: Patka
authors.affiliation: Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.|Department of Viroscience, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Eric C M
authors.initials: EC
authors.lastname: van Gorp
authors.affiliation: Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Pleunie P M
authors.initials: PP
authors.lastname: Rood
mesh_terms: D002097:C-Reactive Protein / Q000032:analysis; D002116:Calcitonin / Q000627:therapeutic use*; D015740:Calcitonin Gene-Related Peptide; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital; D005260:Female; D005334:Fever / Q000188:drug therapy*; D006801:Humans; D008297:Male; D011498:Protein Precursors / Q000627:therapeutic use*
chemical_list: C000606589:CALCA protein, human; D011498:Protein Precursors; D002116:Calcitonin; D002097:C-Reactive Protein; D015740:Calcitonin Gene-Related Peptide
keywords: Antibiotics; C-Reactive protein; Emergency medicine; Fever; Procalcitonin