Clinical question: What is the effectiveness of a procalcitonin (PCT)-based algorithm for the treatment of lower-respiratory-tract infections (LRTIs) compared with standard, evidence-based practice guidelines?

Background: PCT is produced in response to bacterial infection and correlates with disease severity. Prior clinical trials have suggested that the use of serum PCT cutoffs to guide LRTI treatment can reduce antibiotic usage. These previous trials were small in scale, lacked sufficient power, or were compared against nonstandardized controls.

Study design:Multicenter, noninferiority, randomized, controlled trial.

Setting:EDs at six tertiary-care hospitals in Switzerland.

Synopsis:1,381 consecutive ED patients with LRTI were randomized to receive antibiotic therapy based on a PCT-based algorithm or standard evidence-based guidelines. LRTI infections were categorized as acute bronchitis, chronic obstructive pulmonary disease (COPD) exacerbation, or community-acquired pneumonia (CAP). The primary endpoint was a composite of death, ICU admission, disease-specific complication, or recurrent LRTI requiring antibiotics within 30 days.

The composite outcome was similar in both groups. Overall antibiotic exposure was reduced by an average of three days using the PCT-based algorithm (5.7 days vs. 8.7 days), largely because of decreased initiation of antibiotics among patients with acute bronchitis (50.0% vs. 23.2%) and a decreased duration of antibiotic therapy with CAP. This translated into an 8.2% reduction in antibiotic-related complications. Overall antibiotic prescription rates were lower with PCT-based guidelines (75.4% vs. 87.7%); 30-day mortality in the PCT group was slightly higher (5.1% vs. 4.8%), which trended toward significance.

Bottom line: The use of a PCT-based algorithm demonstrates promise as a clinical tool that could help refine LRTI treatment and decrease antibiotic exposure. Questions of long-term safety and generalizability remain unanswered.

Citation: Schuetz P, Christ-Crain M, Thomann R, et al for the ProHOSP Study Group. Effect of procalcitonin-based guidelines vs. standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059-1066.

Reviewed for TH eWireby Anneliese M. Schleyer, MD, MHA, Mark C. Zaros, MD, Angelena Labella, MD, Heather L. Davidson, MD, Reena K. Julka, MD, Anna S. Loge, MD, and Paul R. Sutton, MD, PhD, University of Washington Medicine Hospital and Consultative Medicine Program, Seattle

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