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Dark P, Perkins GD, McMullan R, McAuley D, Gordon AC, Clayton J, Mistry D, Young K, Regan S, McGowan N, Stevenson M, Gates S, Carlson GL, Walsh T, Lone NI, Mouncey PR, Singer M, Wilson P, Felton T, Marshall K, Hossain AM, Lall R. biomArker-guided Duration of Antibiotic treatment in hospitalised Patients with suspecTed Sepsis (ADAPT-Sepsis): A protocol for a multicentre randomised controlled trial. J Intensive Care Soc 2023; 24:427-434. [PMID: 37841304 PMCID: PMC10572477 DOI: 10.1177/17511437231169193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Aim To describe the protocol for a multi-centre randomised controlled trial to determine whether treatment protocols monitoring daily CRP (C-reactive protein) or PCT (procalcitonin) safely allow a reduction in duration of antibiotic therapy in hospitalised adult patients with sepsis. Design Multicentre three-arm randomised controlled trial. Setting UK NHS hospitals. Target population Hospitalised critically ill adults who have been commenced on intravenous antibiotics for sepsis. Health technology Three protocols for guiding antibiotic discontinuation will be compared: (a) standard care; (b) standard care + daily CRP monitoring; (c) standard care + daily PCT monitoring. Standard care will be based on routine sepsis management and antibiotic stewardship. Measurement of outcomes and costs. Outcomes will be assessed to 28 days. The primary outcomes are total duration of antibiotics and safety outcome of all-cause mortality. Secondary outcomes include: escalation of care/re-admission; infection re-lapse/recurrence; antibiotic dose; length and level of critical care stay and length of hospital stay. Ninety-day all-cause mortality rates will also be collected. An assessment of cost effectiveness will be performed. Conclusion In the setting of routine NHS care, if this trial finds that a treatment protocol based on monitoring CRP or PCT safely allows a reduction in duration of antibiotic therapy, and is cost effective, then this has the potential to change clinical practice for critically ill patients with sepsis. Moreover, if a biomarker-guided protocol is not found to be effective, then it will be important to avoid its use in sepsis and prevent ineffective technology becoming widely adopted in clinical practice.
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Affiliation(s)
- Paul Dark
- Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Critical Care Unit, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Greater Manchester, UK
| | - Gavin D Perkins
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Ronan McMullan
- Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Danny McAuley
- Wellcome Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Anthony C Gordon
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, UK
| | - Jonathan Clayton
- Clinical Biochemistry Department, Lancashire Teaching Hospitals NHS Foundation Trust, Sharoe Green Lane, Fulwood, Preston Lancashire, UK
| | - Dipesh Mistry
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Keith Young
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Scott Regan
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Nicola McGowan
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Matt Stevenson
- School of Health and Related Research, The University of Sheffield Western Bank, Sheffield, UK
| | - Simon Gates
- Cancer Research Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Gordon L Carlson
- National Intestinal Failure Centre, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Greater Manchester, UK
| | - Tim Walsh
- Anaesthesia, Critical Care and Pain Medicine, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Nazir I Lone
- Anaesthesia, Critical Care and Pain Medicine, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, Napier House, London, UK
| | - Mervyn Singer
- Centre for Intensive Care Medicine, Experimental and Translational Medicine, Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
| | - Peter Wilson
- Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tim Felton
- Respiratory Academic Group, Division of Immunology, Immunity to Infection and Respiratory Medicine, University of Manchester, Wythenshawe Hospital, Manchester, UK
| | - Kay Marshall
- Pharmacy and Pharmaceutical Sciences, School of Health Sciences, University of Manchester, Manchester, UK
| | - Anower M. Hossain
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Medical School, Clinical Trials Unit, University of Warwick, Coventry, UK
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Correlation of procalcitonin to positive blood culture results in a sample of South African trauma ICU patients between 2016 and 2017. Eur J Trauma Emerg Surg 2020; 47:1183-1188. [PMID: 31897510 DOI: 10.1007/s00068-019-01295-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE This study sought to investigate the screening accuracy of procalcitonin (PCT) for bacteremia, as defined by a positive blood culture, in a South African trauma ICU. METHODS This was a retrospective chart review study involving 149 patients who were admitted to the ICU of a level-1 trauma center in South Africa between 2016 and 2017. Median PCT levels in patients with and without positive blood cultures were compared. The screening accuracy of PCT for a positive blood culture was summarized as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Two PCT cut-points were investigated: a general cut-point in the South African context (> 2.0 ng/mL), and a trauma ICU-specific cut-point (prioritizing specificity while optimizing sensitivity) which was determined from a receiver-operator-characteristic curve. RESULTS Bacteremic patients had higher median PCT levels when compared with non-bacteremic patients (30.5 ng/mL versus 6.6 ng/mL, p = 0.002). The sensitivity, specificity, PPV, and NPV of PCT > 2.0 ng/mL was 86% (95% confidence interval-CI 71-94%), 29% (CI 22-38%), 28% (CI 20-37%), and 87% (CI 73-94%), respectively. The unit-specific cut-point was PCT > 31.0 ng/mL, which had a sensitivity, specificity, PPV, and NPV of 50% (CI 34-66%), 80% (CI 71-86%), 44% (CI 30-59%), and 83% (CI 75-89%), respectively. Unlike PCT > 2.0 ng/mL, PCT > 31.0 ng/mL demonstrated fair-to-good test specificity in a sub-analysis of patients who underwent recent surgery. CONCLUSIONS Increased PCT levels were associated with bacteremia in this study. PCT > 31.0 ng/mL may be used to rule in suspected bacteremia in this trauma ICU setting.
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