Abstract
RationaleLower respiratory tract illness (LRTI) frequently causes adult hospitalization and antibiotic overuse. Procalcitonin (PCT) treatment algorithms have been used successfully in Europe to safely reduce antibiotic use for LRTI but have not been adopted in the United States. We recently performed a feasibility study for a randomized clinical trial (RCT) of PCT and viral testing to guide therapy for non-pneumonic LRTI.ObjectiveThe primary objective of the current study was to understand factors influencing PCT algorithm adherence during the RCT and evaluate factors influencing provider antibiotic prescribing practices for LRTI.Study DesignFrom October 2013-April 2014, 300 patients hospitalized at a community teaching hospital with non-pneumonic LRTI were randomized to standard or PCT-guided care with viral PCR testing. Algorithm adherence data was collected and multivariate stepwise logistic regression of clinical variables used to model algorithm compliance. 134 providers were surveyed anonymously before and after the trial to assess knowledge of biomarkers and viral testing and antibiotic prescribing practices.ResultsDiagnosis of pneumonia on admission was the only variable significantly associated with non-adherence [7% (adherence) vs. 26% (nonadherence), p = 0.01]. Surveys confirmed possible infiltrate on chest radiograph as important for provider decisions, as were severity of illness, positive sputum culture, abnormal CBC and fever. However, age, patient expectations and medical-legal concerns were also at least somewhat important to prescribing practices. Physician agreement with the importance of viral and PCT testing increased from 42% to 64% (p = 0.007) and 49% to 74% (p = 0.001), respectively, after the study.ConclusionsOptimal algorithm adherence will be important for definitive PCT intervention trials in the US to determine if PCT guided algorithms result in better outcomes than reliance on traditional clinical variables. Factors influencing treatment decisions such as patient age, presence of fever, patient expectations and medical legal concerns may be amenable to education to improve PCT algorithm compliance for LRTI.
Highlights
Acute respiratory infections are a frequent cause of medically attended illness in older adults and often require hospitalization
Optimal algorithm adherence will be important for definitive PCT intervention trials in the US to determine if PCT guided algorithms result in better outcomes than reliance on traditional clinical variables
Factors influencing treatment decisions such as patient age, presence of fever, patient expectations and medical legal concerns may be amenable to education to improve PCT algorithm compliance for Lower respiratory tract illness (LRTI)
Summary
Acute respiratory infections are a frequent cause of medically attended illness in older adults and often require hospitalization. The management of mild acute respiratory infection in the outpatient setting is clear, as most infections are due to viruses, illnesses are self-limited, and data showing the safety and benefits of withholding antibiotics are robust.[1,2,3,4] Interventions to reduce unnecessary antibiotics can be focused on provider education and strategies to change behavior.[5,6,7,8,9,10,11] physicians who provide care for patients hospitalized with lower respiratory tract infections (LRTI) are faced with more challenging decisions. Professional societies have espoused an approach de-emphasizing diagnostic testing and promoting empiric antibiotic treatment for community acquired pneumonia (CAP).[12, 16] In addition, the Center for Medicaid Services (CMS) has added pressure to quickly administer antibiotics as a quality measure for patients with pneumonia leading to treatment of many patients with “possible pneumonia” that have other conditions.[17,18,19] The wisdom of these approaches in an era of rising rates of Clostridium difficile colitis and multi-drug resistant organisms is being questioned.[20,21] The use of biomarkers and definitive viral diagnostic testing may provide more accurate targeting of antibiotics to those most likely to benefit, and minimize adverse outcomes.[22,23,24]
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