Procalcitonin Group Research Articles

Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study

PurposeTo compare the efficacy of an antibiotic protocol guided by serum procalcitonin (PCT) with that of standard antibiotic therapy in severe acute exacerbations of COPD (AECOPDs) admitted to the intensive care unit (ICU).MethodsWe conducted a multicenter, randomized trial in France. Patients experiencing severe AECOPDs were assigned to groups whose antibiotic therapy was guided by (1) a 5-day PCT algorithm with predefined cutoff values for the initiation or stoppage of antibiotics (PCT group) or (2) standard guidelines (control group). The primary endpoint was 3-month mortality. The predefined noninferiority margin was 12%.ResultsA total of 302 patients were randomized into the PCT (n = 151) and control (n = 151) groups. Thirty patients (20%) in the PCT group and 21 patients (14%) in the control group died within 3 months of admission (adjusted difference, 6.6%; 90% CI − 0.3 to 13.5%). Among patients without antibiotic therapy at baseline (n = 119), the use of PCT significantly increased 3-month mortality [19/61 (31%) vs. 7/58 (12%), p = 0.015]. The in-ICU and in-hospital antibiotic exposure durations, were similar between the PCT and control group (5.2 ± 6.5 days in the PCT group vs. 5.4 ± 4.4 days in the control group, p = 0.85 and 7.9 ± 8 days in the PCT group vs. 7.7 ± 5.7 days in the control group, p = 0.75, respectively).ConclusionThe PCT group failed to demonstrate non-inferiority with respect to 3-month mortality and failed to reduce in-ICU and in-hospital antibiotic exposure in AECOPDs admitted to the ICU.

The Predictive Role of Procalcitonin On the Treatment of Intra-Abdominal Infections.

AIM:This study aims to evaluate the algorithm of procalcitonin (PCT) and its role on the duration of antibiotics prescription for intra-abdominal infections.MATERIALS AND METHODS:This study is a prospective controlled study that is conducted in groups of 50 hospitalised patients and 50 controlled group patients.RESULTS:The results indicated that the average duration of antibiotic delivery to the PCT group was -10.6 days (SD ± 6.6 days), while in the control group -13.2 days (SD ± 4.2 days). These data showed a significant difference in the duration of antibiotic therapy and the monitoring role of PCTs in the prediction success of antibiotic treatment. The antibiotic delivery was longer in the septic shock 17 (SD ± 11.7) that corresponds to high PCT values of 67.8 (SD ± 50.9). Recurrence of the infection after the cessation of antibiotics occurred in 2 cases (4%) in the standard group, while it occurred in 3 cases (6%) in the control group.CONCLUSION:The treatment of the intra-abdominal infections based on the PCT algorithm shortens the duration of antibiotic treatment and does not pose a risk for the recurrence of the infection.

Monitoring both procalcitonin and C-reactive protein in the early period after tetralogy of Fallot correction in children promotes rational antibiotic use

PurposeThis retrospective cohort study aimed to identify the early postoperative kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in children undergoing tetralogy of Fallot (ToF) correction. The ability of these inflammatory markers to guide rational antibiotic usage was also determined. Materials and MethodsAll consecutive children who underwent ToF correction in 2009–2016 in our referral pediatric cardiac surgery clinic in Gdansk, Poland and did not exhibit infection signs on early postoperative days (POD) were identified. All patients received 48h antibiotic prophylaxis. Antibiotic treatment was extended or empirical antibiotic therapy was introduced if the clinician considered it necessary. CRP and PCT levels were measured on POD1–4 and 1–3, respectively. ResultsOf the 60 eligible children, 44 underwent CRP testing only. The remaining 16 patients underwent both CRP and PCT testing. All patients had abnormally high CRP values after surgery. All patients who also underwent PCT testing also displayed elevated PCT levels. The CRP and PCT levels peaked on POD2 (median=99.8mg/L) and POD1 (median=4.08ng/mL), respectively. In the CRP-alone patients, antibiotic prophylaxis was prolonged or empirical antibiotic therapy was started in 59%; in the CRP and PCT group, this was 25% (p<0.05). ConclusionsThe children had elevated CRP and PCT levels after ToF correction, with peaks observed on POD2 and POD1, respectively. Monitoring both CRP and PCT in the early postoperative period may guide antibiotic therapy, thus reducing unnecessary treatment, additional toxicity, and adverse drug interactions without increasing treatment failure. Rational antibiotic treatment may also reduce antibiotic resistance.

Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections.

Acute respiratory infections (ARIs) comprise of a large and heterogeneous group of infections including bacterial, viral, and other aetiologies. In recent years, procalcitonin (PCT), a blood marker for bacterial infections, has emerged as a promising tool to improve decisions about antibiotic therapy (PCT-guided antibiotic therapy). Several randomised controlled trials (RCTs) have demonstrated the feasibility of using procalcitonin for starting and stopping antibiotics in different patient populations with ARIs and different settings ranging from primary care settings to emergency departments, hospital wards, and intensive care units. However, the effect of using procalcitonin on clinical outcomes is unclear. This is an update of a Cochrane review and individual participant data meta-analysis first published in 2012 designed to look at the safety of PCT-guided antibiotic stewardship. The aim of this systematic review based on individual participant data was to assess the safety and efficacy of using procalcitonin for starting or stopping antibiotics over a large range of patients with varying severity of ARIs and from different clinical settings. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, and Embase, in February 2017, to identify suitable trials. We also searched ClinicalTrials.gov to identify ongoing trials in April 2017. We included RCTs of adult participants with ARIs who received an antibiotic treatment either based on a procalcitonin algorithm (PCT-guided antibiotic stewardship algorithm) or usual care. We excluded trials if they focused exclusively on children or used procalcitonin for a purpose other than to guide initiation and duration of antibiotic treatment. Two teams of review authors independently evaluated the methodology and extracted data from primary studies. The primary endpoints were all-cause mortality and treatment failure at 30 days, for which definitions were harmonised among trials. Secondary endpoints were antibiotic use, antibiotic-related side effects, and length of hospital stay. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable hierarchical logistic regression adjusted for age, gender, and clinical diagnosis using a fixed-effect model. The different trials were added as random-effects into the model. We conducted sensitivity analyses stratified by clinical setting and type of ARI. We also performed an aggregate data meta-analysis. From 32 eligible RCTs including 18 new trials for this 2017 update, we obtained individual participant data from 26 trials including 6708 participants, which we included in the main individual participant data meta-analysis. We did not obtain individual participant data for four trials, and two trials did not include people with confirmed ARIs. According to GRADE, the quality of the evidence was high for the outcomes mortality and antibiotic exposure, and quality was moderate for the outcomes treatment failure and antibiotic-related side effects.Primary endpoints: there were 286 deaths in 3336 procalcitonin-guided participants (8.6%) compared to 336 in 3372 controls (10.0%), resulting in a significantly lower mortality associated with procalcitonin-guided therapy (adjusted OR 0.83, 95% CI 0.70 to 0.99, P = 0.037). We could not estimate mortality in primary care trials because only one death was reported in a control group participant. Treatment failure was not significantly lower in procalcitonin-guided participants (23.0% versus 24.9% in the control group, adjusted OR 0.90, 95% CI 0.80 to 1.01, P = 0.068). Results were similar among subgroups by clinical setting and type of respiratory infection, with no evidence for effect modification (P for interaction > 0.05). Secondary endpoints: procalcitonin guidance was associated with a 2.4-day reduction in antibiotic exposure (5.7 versus 8.1 days, 95% CI -2.71 to -2.15, P < 0.001) and lower risk of antibiotic-related side effects (16.3% versus 22.1%, adjusted OR 0.68, 95% CI 0.57 to 0.82, P < 0.001). Length of hospital stay and intensive care unit stay were similar in both groups. A sensitivity aggregate-data analysis based on all 32 eligible trials showed similar results. This updated meta-analysis of individual participant data from 12 countries shows that the use of procalcitonin to guide initiation and duration of antibiotic treatment results in lower risks of mortality, lower antibiotic consumption, and lower risk for antibiotic-related side effects. Results were similar for different clinical settings and types of ARIs, thus supporting the use of procalcitonin in the context of antibiotic stewardship in people with ARIs. Future high-quality research is needed to confirm the results in immunosuppressed patients and patients with non-respiratory infections.

Dosage de la procalcitonine et bronchiolites vues dans un service d’accueil des urgences pédiatriques

Very few studies have evaluated the role of procalcitonin (PCT) in infants with bronchiolitis. To describe infants who had both a diagnosis of bronchiolitis at the emergency department and a blood test including PCT, and to compare the characteristics of children according to the PCT value. Infants admitted to the Pediatric Emergency Department between 1 January 2014 and 31 December 2014 who had a diagnosis of bronchiolitis and a blood test including PCT were included. The clinical, biological, and radiological characteristics of the infants with PCT <1 or ≥1g/L were compared. One hundred thirty six infants were included. Patients with high PCT (n=20) had a higher temperature (38.5°C, IQR=37.8-38.6 vs. 37.5°C, IQR=37.1-38.2; P<0.01), C-reactive protein (50mg/L, IQR=25-83 vs. 5mg/L, IQR=0-19; P<0.01), and neutrophils (7.8×109/L, IQR=6.0-8.5 vs 4.5×109/L, IQR=2.9-6.6; P<0.01) higher than patients with low PCT (n=116). Presence on the chest x-ray of alveolar condensation did not differ between the two PCT groups. Infants coming from the low-PCT group received fewer antibiotics (14.7% vs 65%; P<0.01). In a Pediatric Emergency Department, PCT with a value of 1 or more cannot predict the presence of alveolar condensation on the chest x-ray. It seems to be associated with the antibiotics prescription, even if this could not be proved because of the design of the study.

A Novel Antimicrobial Stewardship Program-Guided Procalcitonin Initiative for Emergency Department Diagnosis of Bacterial Pneumonia in New York City

BackgroundAn accurate diagnosis of bacterial pneumonia in the Emergency Department (ED) is challenging, resulting in inappropriate antibiotic use, adversely impacting patient care and safety. Procalcitonin (PCT), a serum biomarker, has good positive predictive value for bacterial lower respiratory tract infections. We sought to evaluate the impact of using PCT in an antimicrobial stewardship program (ASP)-driven algorithm to manage patients with presumed pneumonia in the ED.MethodsWe performed an IRB-approved quality initiative, 4-month retrospective evaluation of adult patients evaluated for pneumonia using PCT in a 515-bed university-affiliated hospital. Initial PCT use was restricted to ED for hemodynamically stable patients with presumed pneumonia. Subsequent PCT levels were ordered by ASP team members at 8- to 12-hours and days 3, 5, and 7 to guide the duration of antibiotic use and interpreted as per existing guidelines. Prior to start of initiative, aggressive education was provided by ASP to ED staff, followed by algorithm implementation. Outcomes included hospital admission, days of antibiotics, antibiotic use ≤48 hours, total PCT levels, length of stay, and 30-day pneumonia readmission.ResultsBaseline demographics of initial 182 patients differed between negative and positive PCT groups with age (78 vs. 84, P = 0.037) and sexfemale (88 vs. 15, P = 0.001). Negative PCT was associated with lower temperature (P = 0.0002), and white blood cell count (P = 0.0001) on admission (Figure 1). Patients with negative PCT had reduced antibiotic initiation (71% vs. 95%, P = 0.001) and were less likely to be admitted (89% vs. 98%, P = 0.078). A total of 460 PCT levels were collected [negative group: 303, median 2(2,2), positive group: 157, median 4(3,4)]. Patients with negative PCT had reduced antibiotic duration (P < 0.001) and length of stay (P = 0.004) (Figures 2 and 3). There were no reported adverse events or differences in 30-day pneumonia readmissions.ConclusionImplementation of a PCT algorithm through ASP is a novel and efficacious addition to improving diagnostic yield, targeting appropriate therapy, and reducing length of stay. The impact on antibiotic resistance remains to be determined.Disclosures All authors: No reported disclosures.

Procalcitonin-guided decision making for duration of antibiotic therapy in neonates with suspected early-onset sepsis: a multicentre, randomised controlled trial (NeoPIns)

Up to 7% of term and late-preterm neonates in high-income countries receive antibiotics during the first 3 days of life because of suspected early-onset sepsis. The prevalence of culture-proven early-onset sepsis is 0·1% or less in high-income countries, suggesting substantial overtreatment. We assess whether procalcitonin-guided decision making for suspected early-onset sepsis can safely reduce the duration of antibiotic treatment. We did this randomised controlled intervention trial in Dutch (n=11), Swiss (n=4), Canadian (n=2), and Czech (n=1) hospitals. Neonates of gestational age 34 weeks or older, with suspected early-onset sepsis requiring antibiotic treatment were stratified into four risk categories by their treating physicians and randomly assigned [1:1] using a computer-generated list stratified per centre to procalcitonin-guided decision making or standard care-based antibiotic treatment. Neonates who underwent surgery within the first week of life or had major congenital malformations that would have required hospital admission were excluded. Only principal investigators were masked for group assignment. Co-primary outcomes were non-inferiority for re-infection or death in the first month of life (margin 2·0%) and superiority for duration of antibiotic therapy. Intention-to-treat and per-protocol analyses were done. This trial was registered with ClinicalTrials.gov, number NCT00854932. Between May 21, 2009, and Feb 14, 2015, we screened 2440 neonates with suspected early-onset sepsis. 622 infants were excluded due to lack of parental consent, 93 were ineligible for reasons unknown (68), congenital malformation (22), or surgery in the first week of life (3). 14 neonates were excluded as 100% data monitoring or retrieval was not feasible, and one neonate was excluded because their procalcitonin measurements could not be taken. 1710 neonates were enrolled and randomly assigned to either procalcitonin-guided therapy (n=866) or standard therapy (n=844). 1408 neonates underwent per-protocol analysis (745 in the procalcitonin group and 663 standard group). For the procalcitonin group, the duration of antibiotic therapy was reduced (intention to treat: 55·1 vs 65·0 h, p<0·0001; per protocol: 51·8 vs 64·0 h; p<0·0001). No sepsis-related deaths occurred, and 9 (<1%) of 1710 neonates had possible re-infection. The risk difference for non-inferiority was 0·1% (95% CI -4·6 to 4·8) in the intention-to-treat analysis (5 [0·6%] of 866 neonates in the procalcitonin group vs 4 [0·5%] of 844 neonates in the standard group) and 0·1% (-5·2 to 5·3) in the per-protocol analysis (5 [0·7%] of 745 neonates in the procalcitonin group vs 4 [0·6%] of 663 neonates in the standard group). Procalcitonin-guided decision making was superior to standard care in reducing antibiotic therapy in neonates with suspected early-onset sepsis. Non-inferiority for re-infection or death could not be shown due to the low occurrence of re-infections and absence of study-related death. The Thrasher Foundation, the NutsOhra Foundation, the Sophia Foundation for Scientific research.

Comparison of Procalcitonin Guidance-Administered Antibiotics with Standard Guidelines on Antibiotic Therapy in Children with Lower Respiratory Tract Infections: A Retrospective Study in China

Objective: To establish the efficacy of an algorithm based on the biomarker procalcitonin (PCT) to reduce antibiotic exposure in pediatric patients with lower respiratory tract infection (LRTI). Materials and Methods: The clinical data of 357 patients (<14 years of age) who were discharged home with LRTI from January 1, 2010 to July 31, 2016 were analyzed. Antibiotic exposure, antibiotic prescription rate, length of hospital stay, and antibiotic-associated adverse effects were compared between the PCT group (n = 183) and the standard group (n = 174) using SAS 9.1.3 software. Results: The overall adverse effect rates were similar in both the PCT and standard groups: 42 (22.95%) and 51 (29.31%), respectively. The length of hospital stay was not significantly different between the PCT (9.96 ± 5.81 days) and standard groups (10.58 ± 4.24 days) (difference: -0.62%; 95% CI: -1.68 to 0.43). Antibiotic prescribing rates were significantly different in the PCT group compared to the standard group: 54.64% versus 83.91% (difference: -29.26%; 95% CI: -38.31, -20.22; p = 0.23). Mean duration of antibiotic exposure in the PCT group (3.98 ± 2.17 days) was lower than the standard groups (6.66 ± 5.59 days) (difference: -2.68%; 95% CI: -3.21 to -2.16). Conclusion: This study showed that PCT guidance of antibiotic treatment in children and adolescents with LRTI reduced the duration of antibiotic exposure and antibiotic prescribing rates, but did not affect the adverse effect rate and length of hospital stay.

Procalcitonin-Guided Antibiotics after Surgery for Peritonitis: A Randomized Controlled Study.

Background Serum procalcitonin (PCT) is a useful biomarker to tailor the duration of antibiotics in respiratory infections. The objective of this study was to determine whether PCT levels could tailor postoperative antibiotic therapy in patients operated for peritonitis. Method Patients with peritonitis were randomized postoperatively. The control group received antibiotics for a defined duration according to institutional guidelines. In the study group, antibiotics were stopped based on serum PCT levels. Patients were stratified into three categories: (1) gastrointestinal perforation, (2) perforated appendicitis, and (3) postoperative complication. Primary outcome was duration of antibiotics. Results We included 162 patients; 83 and 79 patients in the control group and study group, respectively. In the subgroup of patients with peritonitis due to gastrointestinal perforation, we found 7 days of antibiotics in the PCT group versus 10 days in the control group (p value 0.065). There was no difference in infectious complications, mortality, median length of hospital stay, and necessity to restart antibiotics. Conclusion No significant differences were found in duration of antibiotics when applying PCT guidance. However, in the subgroup of primary perforation of the gastrointestinal tract, there was a difference in duration of antibiotics in favor of the PCT group without obtaining significance, as the study was not powered for subgroup analysis. Further studies including only this subgroup should be performed.

Serum Procalcitonin: An Independent Predictor of Clinical Outcome in Health Care-Associated Pneumonia

Background: Early prediction of the clinical outcomes for health care-associated pneumonia (HCAP) patients is challenging. Objectives: This is the first study to evaluate procalcitonin (PCT) as a predictor of outcomes in HCAP patients. Methods: We conducted an observational study based on data for HCAP patients prospectively collected between 2011 and 2014. Outcome variables were intensive care unit (ICU) admission and 30-day mortality. PCT was categorized into three groups: <0.5, 0.5-2.0, and >2.0 ng/ml. We analysed multiple variables including age, sex, comorbidities, clinical findings, and PCT group to assess their association with outcomes. Results: Of 245 HCAP patients, 99 (40.4%) were admitted to an ICU and 44 (18.0%) died within 30 days. The median PCT level was significantly higher in the ICU admission (1.19 vs. 0.4 ng/ml; p < 0.001) and 30-day mortality (3.3 vs. 0.4 ng/ml; p < 0.001) groups. In multivariate analysis, high PCT (>2.0 ng/ml) was strongly associated with ICU admission [odds ratio 3.734, 95% confidence interval (CI) 1.753-7.951; p = 0.001] and 30-day mortality (hazard ratio 2.254, 95% CI 1.250-5.340; p = 0.035). In receiver operating characteristic analysis, PCT had a poor discrimination power regarding ICU admission [0.695 of the area under the curve (AUC)] and a fair discrimination power regarding 30-day mortality in HCAP patients (0.768 of the AUC). Conclusions: High PCT on admission was strongly associated with ICU admission and 30-day mortality in HCAP patients. However, application of PCT alone seems to be limited to predicting outcomes.

Effect of Procalcitonin Testing on Health-care Utilization and Costs in Critically Ill Patients in the United States

There is a growing use of procalcitonin (PCT) to facilitate the diagnosis and management of severe sepsis. We investigated the impact of one to two PCT determinations on ICU day 1 on health-care utilization and cost in a large research database. A retrospective, propensity score-matched multivariable analysis was performed on the Premier Healthcare Database for patients admitted to the ICU with one to two PCT evaluations on day 1 of ICU admission vspatients who did not have PCT testing. A total of 33,569 PCT-managed patients were compared with 98,543 propensity score-matched non-PCT patients. In multivariable regression analysis, PCT utilization was associated with significantly decreased total length of stay (11.6days [95%CI, 11.4 to 11.7] vs12.7days [95%CI, 12.6 to 12.8]; 95%CI for difference, 1 to 1.3; P< .001) and ICU length of stay (5.1days [95%CI, 5.1 to 5.2] vs5.3days [95%CI, 5.3 to 5.4]; 95%CI for difference, 0.1 to 0.3; P< .03), and lower hospital costs ($30,454 [95%CI, 29,968 to 31,033] vs$33,213 [95%CI, 32,964 to 33,556); 95%CI for difference, 2,159 to 3,321; P< .001). There was significantly less total antibiotic exposure (16.2days [95%CI, 16.1 to 16.5] vs16.9days [95%CI, 16.8 to 17.1]; 95%CI for difference, -0.9 to 0.4; P= .006) in PCT-managed patients. Patients in the PCT group were more likely to be discharged to home (44.1%[95%CI, 43.7 to 44.6] vs41.3%[95%CI, 41 to 41.6]; 95%CI for difference, 2.3 to 3.3; P= .006). Mortality was not different in an analysis including the 96%of patients who had an independent measure of mortality risk available (19.1%[95%CI, 18.7 to 19.4] vs19.1%[95%CI, 18.9 to 19.3]; 95%CI for difference, -0.5 to 0.4; P= .93). Use of PCT testing on the first day of ICU admission was associated with significantly lower hospital and ICU lengths of stay, as well as decreased total, ICU, and pharmacy cost of care. Further elucidation of clinical outcomes requires additional data.

The Prevalence and Clinical Significance of Low Procalcitonin Levels Among Patients With Severe Sepsis or Septic Shock in the Emergency Department.

The aims of this study were to evaluate the prevalence of low procalcitonin (PCT) levels among patients with severe sepsis or septic shock, and to investigate clinical characteristics and outcomes associated with low PCT levels. We analyzed data from the sepsis registry for patients with severe sepsis or septic shock in the emergency department. Based on a specific PCT cutoff value, patients were classified into two groups: a low PCT group, PCT <0.25 ng/mL; and a high PCT group, PCT ≥0.25 ng/mL. The primary endpoint was 28-day mortality. A multivariable logistic regression model was used to evaluate independent factors associated with low PCT and 28-day mortality. A total of 1,212 patients were included. Of the eligible patients, 154 (12.7%) were assigned to the low PCT group, and 1,058 (87.3%) to the high PCT group. The 28-day mortality was 4.6% in the low PCT group and 13.5% in the high PCT group (P < 0.01). The adjusted odds ratio of the low PCT group for 28-day mortality was 0.43 (95% CI 0.19-0.98; P = 0.04). There was no trend of increasing mortality among higher PCT level patients. In a logistic regression model, factors associated with low PCT were pneumonia, lower C-reactive protein levels, lower lactate levels, the absence of bacteremia, and the absence of organ failure. Intra-abdominal infection and obesity were associated with high PCT. Initial low PCT levels were common among patients diagnosed with severe sepsis or septic shock in the emergency department, suggesting favorable outcomes. The prevalence of low PCT levels was significantly different according to obesity, the source of infection, C-reactive protein levels, lactate levels, bacteremia, and organ failure.

Procalcitonin-guided protocol is not useful to manage antibiotic therapy in febrile neutropenia: a randomized controlled trial.

Febrile neutropenia (FN) requires immediate use of antibiotics (ATB), and procalcitonin (PCT) is proven to be useful in guiding antibiotic therapy in different settings. This study investigated the use of PCT as a guide for the duration of ATB in FN. A randomized controlled trial was carried out from January-December 2010. A total of 62 hematological adult patients with FN were randomized, in 1:1 ratio, into two groups: (1) PCT group: length of ATB guided by institutional protocol plus PCT dynamics, and (2) control group: duration of ATB in accordance with institutional protocol. There was no difference between groups regarding the use of ATB for the first episode of fever (HR 1.14, 95% CI 0.66-1.95, p = 0.641), with equivalent median duration of ATB therapy (PCT group 9.0days and control group 8.0days, p = 0.67), and median number of days without ATB (0days, IQR 0-2days for both groups, p = 0.96). We observed no difference in clinical cure rate (p = 0.68), infection relapse (p = 1.0), superinfection (p = 0.85), length of hospitalization (p = 0.64), and mortality at 28days (p = 0.39) and at 90days (p = 0.72). Considering the cut-off of 0.5ng/ml, PCT was correlated with bacteremia (sensitivity of 51.9% and specificity of 76.5%). In this randomized controlled trial, adding a PCT-guided protocol to the standard recommendations did not reduce the use of antibiotics in febrile neutropenia, although no apparent harm was caused. PCT proved to be a marker of bacteremia in this setting.

Antibiotic therapy decision and clinical outcome comparison based on serum procalcitonin in children with pneumonia

Purpose: It is difficult to differentiate between viral and bacterial pneumonia in children and to decide antibiotic therapy. Study was conducted to investigate the clinical usefulness of antibiotic therapy based on procalcitonin (PCT) in children diagnosed with viral pneumonia. Methods: This study included 108 patients diagnosed with viral pneumonia. Patient’s age, fever duration, hospital stay, and treatment progress were noted, and laboratory study including PCT levels were tested. In addition, Polymerase chain reaction was done to test for viruses. Patients were divided into PCT and non-PCT groups according to PCT level. And their clinical patterns, treatment outcome, antibiotic use, severity of complications were compared. Results: The number of patients with respiratory syncytial virus (RSV) was 35 and 50, rhinovirus was 5 and 10 in PCT and non-PCT groups, respectively. Fever duration was longer by 2.5 days in PCT group than in the non-PCT group (P<0.001), but there was no difference in the duration of hospital stay (P=0.191). White blood cell and absolute neutrophil count levels were higher in the PCT group (P=0.013 and P<0.001, respectively). Use of antibiotic therapy was performed in group was on 22% and 90% of patients in the PCT and non-PCT groups, respectively showing a significant reduction in the frequency of antibiotic therapy in PCT group, without a significant difference in treatment outcome, despite more severe clinical signs (P<0.001). Conclusion: Antibiotic therapy based on serum PCT levels in children admitted for pneumonia can reduce the frequency of antibiotic therapy in viral pneumonia, without causing significantly different treatment outcome or complications.

Antibiotic Treatment of Severe Exacerbations of Chronic Obstructive Pulmonary Disease with Procalcitonin: A Randomized Noninferiority Trial

BackgroundThe duration of antibiotic treatment of exacerbations of COPD (ECOPD) is controversial. Serum procalcitonin (PCT) is a biomarker of bacterial infection used to identify the cause of ECOPD.Methods and FindingsWe investigated whether a PCT-guided plan would allow a shorter duration of antibiotic treatment in patients with severe ECOPD. For this multicenter, randomized, non-inferiority trial, we enrolled 184 patients hospitalized with ECOPD from 18 hospitals in Italy. Patients were assigned to receive antibiotics for 10 days (standard group) or for either 3 or 10 days (PCT group). The primary outcome was the rate of ECOPD at 6 months. Having planned to recruit 400 patients, we randomized only 183: 93 in the PCT group and 90 in the standard group. Thus, the completed study was underpowered. The ECOPD rate at 6 months between PCT-guided and standard antibiotic treatment was not significant (% difference, 4.04; 90% confidence interval [CI], −7.23 to 15.31), but the CI included the non-inferiority margin of 15. In the PCT-guided group, about 50% of patients were treated for 3 days, and there was no difference in primary or secondary outcomes compared to patients treated for 10 days.ConclusionsAlthough the primary and secondary clinical outcomes were no different for patients treated for 3 or 10 days in the PCT group, the conclusion that antibiotics can be safely stopped after 3 days in patients with low serum PCT cannot be substantiated statistically. Thus, the results of this study are inconclusive regarding the noninferiority of the PCT-guided plan compared to the standard antibiotic treatment. The study was funded by Agenzia Italiana del Farmaco (AIFA-FARM58J2XH). Clinical trial registered with www.clinicaltrials.gov (NCT01125098).Trial RegistrationClinicalTrials.gov NCT01125098

Serum procalcitonin level and SOFA score at discharge from the intensive care unit predict post-intensive care unit mortality: a prospective study.

PurposeThe final decision for discharge from the intensive care unit (ICU) is uncertain because it is made according to various patient parameters; however, it should be made on an objective evaluation. Previous reports have been inconsistent and unreliable in predicting post-ICU mortality. To identify predictive factors associated with post-ICU mortality, we analyzed physiological and laboratory data at ICU discharge.MethodsPatients admitted to our ICU between September 2012 and August 2013 and staying for critical care>2 days were included. Sequential Organ Failure Assessment (SOFA) score; systemic inflammatory response syndrome score; white blood cell count; and serum C reactive protein, procalcitonin (PCT), interleukin-6 (IL-6), lactate, albumin, and hemoglobin levels were recorded. The primary end point was 90-day mortality after ICU discharge. Two hundred eighteen patients were enrolled (195 survivors, 23 non-survivors).ResultsNon-survivors presented a higher SOFA score and serum PCT, and IL-6 levels, as well as lower serum albumin and hemoglobin levels. Serum PCT, albumin, and SOFA score were associated with 90-day mortality in multiple logistic regression analysis. Hosmer-Lemeshow test showed chi-square value of 6.96, and P value of 0.54. The area under the curve (95% confidence interval) was 0.830 (0.771–0.890) for PCT, 0.688 (0.566–0.810) for albumin, 0.861 (0.796–0.927) for SOFA score, and increased to 0.913 (0.858–0.969) when these were combined. Serum PCT level at 0.57 ng/mL, serum albumin at 2.5 g/dL and SOFA score at 5.5 predict 90-day mortality, and high PCT, low albumin and high SOFA groups had significantly higher mortality. Serum PCT and SOFA score were significantly associated with survival days after ICU discharge in Cox regression analysis.ConclusionsSerum PCT level and SOFA score at ICU discharge predict post-ICU mortality and survival days after ICU discharge. The combination of these two and albumin level might enable accurate prediction.

Procalcitonin guidance for reduction of antibiotic use in patients hospitalized with severe acute exacerbations of asthma: a randomized controlled study with 12-month follow-up.

IntroductionPatients with severe acute exacerbations of asthma often receive inappropriate antibiotic treatment. We aimed to determine whether serum procalcitonin (PCT) levels can effectively and safely reduce antibiotic exposure in patients experiencing exacerbations of asthma.MethodsIn this randomized controlled trial, a total of 216 patients requiring hospitalization for severe acute exacerbations of asthma were screened for eligibility to participate and 169 completed the 12-month follow-up visit. Patients were randomized to either PCT-guided (PCT group) or standard (control group) antimicrobial therapy. In the control group, patients received antibiotics according to the attending physician’s discretion; in the PCT group, patients received antibiotics according to an algorithm based on serum PCT levels. The primary end point was antibiotic exposure; secondary end points were clinical recovery, length of hospital stay, clinical and laboratory parameters, spirometry, number of asthma exacerbations, emergency room visits, hospitalizations and need for corticosteroid use due to asthma.ResultsPCT guidance reduced antibiotic prescription (48.9% versus 87.8%, respectively; P < 0.001) and antibiotic exposure (relative risk, 0.56; 95% confidence interval, 0.44 to 0.70; P < 0.001) compared to standard therapy. There were no significant differences in clinical recovery, length of hospital stay or clinical, laboratory and spirometry outcomes in both groups. Number of asthma exacerbations, emergency room visits, hospitalizations and need for corticosteroid use due to asthma were similar during the 12-month follow-up period.ConclusionA PCT-guided strategy allows antibiotic exposure to be reduced in patients with severe acute exacerbation of asthma without apparent harm.Trial registrationChinese Clinical Trial Register ChiCTR-TRC-12002534 (registered 26 September 2012)

Clinical significance of serum procalcitonin level for rational use of antibiotics in patients with acute upper respiratory tract infection

Objective To explore the clinical significance of serum procalcitonin (PCT) level in the diagnosis and treatment of patients with acute upper respiratory tract infection.Methods 199 patients with acute upper respiratory tract infection treated at Jiangmen central hospital from Jan 2013 to Nov 2013 were divided into a conventional group(n=101) and a PCT group(n=98).The conventional group was treated with antibiotic according to the antibiotic guidance,while the PCT group with antibiotic according to serum PCT levels.Both groups were also treated with routine therapy.The clinical efficacies,defervescence times,ratio of antibiotics usage,courses of antibiotics treatment and incidences of adverse reaction in both groups were observed.The cost of antibiotics and total cost were compared between the two groups.Results The ratio of antibiotics usage,course of antibiotics treatment,cost of antibiotics,and total costs were 51.49％,(3.01 ± 0.77) d,(159.98 ± 188.17) yuan,and (880.42 ± 349.16) yuan in the PCT group and were 90.82％,(4.37 ± 0.62) d,(228.71 ± 147.85) yuan,and (975.22 ± 403.02) yuan in the conventional group,with statistical differences (P ＜ 0.05).There were no significant differences in clinical efficacy and defervescence time between the PCT group and conventional group(89.1 1％ vs.92.86％,[3.29 ± 1.45] d vs.[3.40 ± 1.69] d).Conclusions Serum PCT level is useful for guiding antibiotics usage in the patients with acute upper respiratory tract infection. Key words: Acute upper respiratory tract infection; Procalcitonin; Antibiotics

ABSTRACT 631

Background and aims: procalcitonin (procalcitonin PCT) as a new index infection monitoring has been paid more and more attention, the plasma PCT level is closely related to the severity of bacterial infection and its prognosis Aims: To evaluate the value of serum procalcitonin (PCT) in antibiotics used for the treatment of pneumonia in children. Methods: 272 patients with pneumonia were randomly assigned to PCT group and control group.Patients in the PCT group were treated with antibiotics guided by the levels of serum PCT. The antibiotics treatment was stopped or not used if PCT level<0.25μg/L.Conventional treatment group by the treating physician in accordance with antibiotics user guide decision whether or not to use antibiotics. To compare the duration of antibiotic therapy, the exposure of antibiotic in two group and observe the PCT levels changes after the treatment with antibiotics in PCT group. Results: The duration of antibiotic therapy and the exposure of antibiotic in PCT group was significantly shorter than that in the control group (p<0.05), But the prognosis in two group have not significant difference. The PCT levels after after 5 and 7 days of treatment was significantly lower than on admission (c2= 15.86, c2= 18.86 respectively, p<0.01). Conclusions: Dynamic monitoring of PCT levels to guide the exposure of antibiotic in pediatric pneumonia, can reduce the exposure of antibiotic, and shorten the duration of antibiotic therapy and the length of hospital stays.

The value of procalcitonin in diagnosis and treatment of neonatal ventilator associated pneumonia

Objective To explore the value of procalcitonin (PCT) in diagnosis and treatment of neonatal ventilator associated pneumonia (VAP). Methods Sixty neonates needed invasive mechanical ventilation admitted to our NICU from Jan 2012 to Dec 2013 were divided into VAP group (30 cases) and non-VAP group (30 cases), depending on whether the neonates developed to VAP or not in 7 days. The VAP group then was randomly divided into PCT group (15 cases) and control group (15 cases) according to random number table. The levels of serum PCT, C-reactive protein (CRP) and WBC count were detected when the neonates suspected VAP before and after mechanical ventilation. Besides, the sensitivity, specificity, positive and negative predictive values for PCT, CRP and WBC were calculated in the diagnosis of VAP. Results The serum levels of PCT in VAP group had significant difference before and after mechanical ventilation (t=1.58, P=0.000), the levels of PCT were (0.37±0.25) μg/L and (2.17±1.46) μg/L respectively. The levels of PCT in non-VAP group had no significant difference (t=3.67, P=0.055). The levels of CRP and WBC showed no significant differences between VAP and non-VAP group before mechanical ventilation (P>0.05). Taking PCT≥0.40 μg/L, CRP≥28 mg/L and WBC≥10×109/L as the cut off value, the sensitivity of the three indicators diagnosis of VAP were 93.3%, 73.3% and 66.7% respectively. PCT had the highest sensitivity 93.3%, specificity 73.3%, positive predictive 77.8% and negative predictive 91.7%. The antibiotic duration of PCT group was (12.6±5.6) d compared with (15.1±9.1) d in control group (P=0.018). Conclusion Serum PCT has high sensitivity and specificity in the diagnosis of VAP, PCT combined with clinical pulmonary infection score can improve the diagnostic accuracy of VAP, early diagnosis and timely monitoring of serum PCT is helpful in VAP. PCT guidance substantially reduces antibiotic use in VAP, so that timely surveillance of PCT is necessary for patients on ventilator. Key words: Procalcitonin; Ventilator associated pneumonia; Clinical pulmonary infection score