Abstract
BackgroundProcalcitonin (PCT)-based algorithms have been used to guide antibiotic therapy in several clinical settings. However, evidence supporting PCT-based algorithms for secondary peritonitis after emergency surgery is scanty. In this study, we aimed to investigate whether a PCT-based algorithm could safely reduce antibiotic exposure in this population.Methods/Principal FindingsFrom April 2012 to March 2013, patients that had secondary peritonitis diagnosed at the emergency department and underwent emergency surgery were screened for eligibility. PCT levels were obtained pre-operatively, on post-operative days 1, 3, 5, and 7, and on subsequent days if needed. Antibiotics were discontinued if PCT was <1.0 ng/mL or decreased by 80% versus day 1, with resolution of clinical signs. Primary endpoints were time to discontinuation of intravenous antibiotics for the first episode and adverse events. Historical controls were retrieved for propensity score matching. After matching, 30 patients in the PCT group and 60 in the control were included for analysis. The median duration of antibiotic exposure in PCT group was 3.4 days (interquartile range [IQR] 2.2 days), while 6.1 days (IQR 3.2 days) in control (p < 0.001). The PCT algorithm significantly improves time to antibiotic discontinuation (p < 0.001, log-rank test). The rates of adverse events were comparable between 2 groups. Multivariate-adjusted extended Cox model demonstrated that the PCT-based algorithm was significantly associated with a 87% reduction in hazard of antibiotic exposure within 7 days (hazard ratio [HR] 0.13, 95% CI 0.07–0.21, p < 0.001), and a 68% reduction in hazard after 7 days (adjusted HR 0.32, 95% CI 0.11–0.99, p = 0.047). Advanced age, coexisting pulmonary diseases, and higher severity of illness were significantly associated with longer durations of antibiotic use.Conclusions/SignificanceThe PCT-based algorithm safely reduces antibiotic exposure in this study. Further randomized trials are needed to confirm our findings and incorporate cost-effectiveness analysis.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12612000601831
Highlights
Intra-abdominal infection is a common problem in clinical practice, and is the second most common cause of infectious mortality in the intensive care unit [1]
The aims of this study was to investigate whether a PCT-based algorithm could safely reduce the duration of intravenous antibiotic exposure for the first episode among patients with secondary peritonitis after emergency surgery, and provided further information for future randomized trials
Our prospective study indicated that the PCT-guided algorithm, compared to the standard of care, significantly reduced the hazard of antibiotic exposure among patients with secondary peritonitis following emergency surgery
Summary
Intra-abdominal infection is a common problem in clinical practice, and is the second most common cause of infectious mortality in the intensive care unit [1]. Recent development of biomarkers such as the procalcitonin (PCT) assay has facilitated antibiotic therapy in several clinical settings [3,4,5,6]. An observation study demonstrates that concentration of PCT declines from the first postoperative day and reaches half of its initial value by the second day, whereas the mean concentration of C-reactive protein increases in the first 48 hours and reaches half of its maximum value on the fifth day [12]. Since its higher specificity and earlier return to the physiological levels after surgery, PCT should have the ability to help exclude bacterial infections in the early postoperative period. Procalcitonin (PCT)-based algorithms have been used to guide antibiotic therapy in several clinical settings. We aimed to investigate whether a PCT-based algorithm could safely reduce antibiotic exposure in this population
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