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Schuetz P, Christ-Crain M, Wolbers M, Schild U, Thomann R, Falconnier C, Widmer I, Neidert S, Blum CA, Schönenberger R, Henzen C, Bregenzer T, Hoess C, Krause M, Bucher HC, Zimmerli W, Müller B. Procalcitonin guided antibiotic therapy and hospitalization in patients with lower respiratory tract infections: a prospective, multicenter, randomized controlled trial. BMC Health Serv Res 2007; 7:102. [PMID: 17615073 PMCID: PMC1947969 DOI: 10.1186/1472-6963-7-102] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 07/05/2007] [Indexed: 02/01/2023] Open
Abstract
Background: Lower respiratory tract infections like acute bronchitis, exacerbated chronic obstructive pulmonary disease and community-acquired pneumonia are often unnecessarily treated with antibiotics, mainly because of physicians' difficulties to distinguish viral from bacterial cause and to estimate disease-severity. The goal of this trial is to compare medical outcomes, use of antibiotics and hospital resources in a strategy based on enforced evidence-based guidelines versus procalcitonin guided antibiotic therapy in patients with lower respiratory tract infections. Methods and design: We describe a prospective randomized controlled non-inferiority trial with an open intervention. We aim to randomize over a fixed recruitment period of 18 months a minimal number of 1002 patients from 6 hospitals in Switzerland. Patients must be >18 years of age with a lower respiratory tract infections <28 days of duration. Patients with no informed consent, not fluent in German, a previous hospital stay within 14 days, severe immunosuppression or chronic infection, intravenous drug use or a terminal condition are excluded. Randomization to either guidelines-enforced management or procalcitonin-guided antibiotic therapy is stratified by centre and type of lower respiratory tract infections. During hospitalization, all patients are reassessed at days 3, 5, 7 and at the day of discharge. After 30 and 180 days, structured phone interviews by blinded medical students are conducted. Depending on the randomization allocation, initiation and discontinuation of antibiotics is encouraged or discouraged based on evidence-based guidelines or procalcitonin cut off ranges, respectively. The primary endpoint is the risk of combined disease-specific failure after 30 days. Secondary outcomes are antibiotic exposure, side effects from antibiotics, rate and duration of hospitalization, time to clinical stability, disease activity scores and cost effectiveness. The study hypothesis is that procalcitonin-guidance is non-inferior (i.e., at worst a 7.5% higher combined failure rate) to the management with enforced guidelines, but is associated with a reduced total antibiotic use and length of hospital stay. Discussion: Use of and prolonged exposure to antibiotics in lower respiratory tract infections is high. The proposed trial investigates whether procalcitonin-guidance may safely reduce antibiotic consumption along with reductions in hospitalization costs and antibiotic resistance. It will additionally generate insights for improved prognostic assessment of patients with lower respiratory tract infections. Trial registration: ISRCTN95122877
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Affiliation(s)
- Philipp Schuetz
- Department of Internal Medicine and Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Basel Institute of Clinical Epidemiology (BICE), University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Mirjam Christ-Crain
- Department of Internal Medicine and Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Marcel Wolbers
- Basel Institute of Clinical Epidemiology (BICE), University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Ursula Schild
- Department of Internal Medicine and Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Robert Thomann
- Department of Internal Medicine and Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Departement of Internal Medicine Bürgerspital Solothurn, Schöngrünstrasse 42, 4500 Solothurn, Switzerland
| | - Claudine Falconnier
- Department of Internal Medicine and Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
- Departement of Internal Medicine Kantonsspital Liestal, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Isabelle Widmer
- Departement of Internal Medicine Kantonsspital Luzern, Spitalstrasse, 6000 Luzern 16, Switzerland
| | - Stefanie Neidert
- Departement of Internal Medicine Kantonsspital Luzern, Spitalstrasse, 6000 Luzern 16, Switzerland
| | - Claudine A Blum
- Departement of Internal Medicine Kantonsspital Aarau, Tellstrasse, 5001 Aarau, Switzerland
| | - Ronald Schönenberger
- Departement of Internal Medicine Bürgerspital Solothurn, Schöngrünstrasse 42, 4500 Solothurn, Switzerland
| | - Christoph Henzen
- Departement of Internal Medicine Kantonsspital Luzern, Spitalstrasse, 6000 Luzern 16, Switzerland
| | - Thomas Bregenzer
- Departement of Internal Medicine Kantonsspital Aarau, Tellstrasse, 5001 Aarau, Switzerland
| | - Claus Hoess
- Departement of Internal Medicine Kantonsspital Münsterlingen, 8596 Münsterlingen, Switzerland
| | - Martin Krause
- Departement of Internal Medicine Kantonsspital Münsterlingen, 8596 Münsterlingen, Switzerland
| | - Heiner C Bucher
- Basel Institute of Clinical Epidemiology (BICE), University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Werner Zimmerli
- Departement of Internal Medicine Kantonsspital Liestal, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Beat Müller
- Department of Internal Medicine and Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
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