Procalcitonin-Guided Treatment on Duration of Antibiotic Therapy and Cost in Septic Patients (PRODA): a Multi-Center Randomized Controlled Trial

Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis

BACKGROUND

Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients.

METHODS

We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes.

RESULTS

We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively).

CONCLUSIONS

PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.

Biomarkers in the intensive care setting: A focus on using procalcitonin and C-reactive protein to optimize antimicrobial duration of therapy

Managing the critically ill patient with infection is complex, requiring clinicians to synthesize considerable information relating to antimicrobial efficacy and treatment duration. The use of biomarkers may play an important role in identifying variation in treatment response and providing information about treatment efficacy. Though a vast number of biomarkers for clinical application have been described, procalcitonin and C-reactive protein (CRP) are the most thoroughly investigated in the critically ill. However, the presence of heterogeneous populations, variable end points, and incongruent methodology in the literature complicates the use of such biomarkers to guide antimicrobial therapy. This review focuses on an appraisal of evidence for use of procalcitonin and CRP to optimize antimicrobial duration of therapy (DOT) in critically ill patients. Procalcitonin-guided antimicrobial therapy in mixed critically ill populations with varying degrees of sepsis appears to be safe and might assist in reducing antimicrobial DOT. Compared to procalcitonin, fewer studies exist examining the impact of CRP on antimicrobial DOT and clinical outcomes in the critically ill. Procalcitonin and CRP have been insufficiently studied in many key intensive care unit populations, including surgical patients with concomitant trauma, renally insufficient populations, the immunocompromised, and patients with septic shock. We believe the available evidence is not strong enough to warrant routine use of procalcitonin or CRP to guide antimicrobial DOT in critically ill patients with infection. So long as its limitations are recognized, procalcitonin could be considered to tailor antimicrobial DOT on a case-by-case basis in the critically ill patient.

Antimicrobial stewardship in the intensive care unit

High resistance rates to antimicrobials continue to be a global health threat. The incidence of multidrug-resistant (MDR) microorganisms in intensive care units (ICUs) is quite high compared to in the community and other units in the hospital because ICU patients are generally older, have higher numbers of co-morbidities and immune-suppressed; moreover, the typically high rates of invasive procedures performed in the ICU increase the risk of infection by MDR microorganisms. Antimicrobial stewardship (AMS) refers to the implementation of coordinated interventions to improve and track the appropriate use of antibiotics while offering the best possible antibiotic prescription (according to dose, duration, and route of administration). Broad-spectrum antibiotics are frequently preferred in ICUs because of greater infection severity and colonization and infection by MDR microorganisms. For this reason, a number of studies on AMS in ICUs have increased in recent years. Reducing the use of broad-spectrum antibiotics forms the basis of AMS. For this purpose, parameters such as establishing an AMS team, limiting the use of broad-spectrum antimicrobials, terminating treatments early, using early warning systems, pursuing infection control, and providing education and feedback are used. In this review, current AMS practices in ICUs are discussed.

One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers

INTRODUCTION

Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals.

AREAS COVERED

In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care.

EXPERT OPINION

In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.

Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial

Background

In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients.

Materials and methods

Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients.

Results

In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33).

Conclusions

In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.

Implementation of Procalcitonin in Antibiotic Stewardship: Derivation of a Consensus Algorithm for Procalcitonin Use in Clinical Practice

Reducing antibiotics overuse is essential to minimize antibiotics related side effects and to prevent the emergence of multidrug-resistant bacteria. Procalcitonin (PCT) guided antibiotics therapy has been reported to be safe in patients with acute respiratory infections and sepsis, improving clinical outcomes as well as reducing the duration of antibiotics use. However, there is still no universal agreement on clinical guidelines in Korea for optimal PCT applications. Through this expert consensus meeting, clinical research findings in the PCT-guided antibiotics treatment interventions and real-world clinical applications were discussed. From the perspective of antibiotic stewardship, PCT application target groups, cut-offs, and testing cycles were discussed to reach a consensus on the PCT-guided antibiotics treatment algorithm for application in Korea. Combining clinical assessment for patients with an appropriate PCT-guided antibiotics treatment algorithm could improve the diagnosis and treatment of acute respiratory infections and sepsis. In addition, continuous education and regular feedback would improve the effectiveness of antibiotic stewardship.

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Antimicrobial Stewardship Using Biomarkers: Accumulating Evidence for the Critically Ill

This review aims to summarize current progress in the management of critically ill, using biomarkers as guidance for antimicrobial treatment with a focus on antimicrobial stewardship. Accumulated evidence from randomized clinical trials (RCTs) and observational studies in adults for the biomarker-guided antimicrobial treatment of critically ill (mainly sepsis and COVID-19 patients) has been extensively searched and is provided. Procalcitonin (PCT) is the best studied biomarker; in the majority of randomized clinical trials an algorithm of discontinuation of antibiotics with decreasing PCT over serial measurements has been proven safe and effective to reduce length of antimicrobial treatment, antibiotic-associated adverse events and long-term infectious complications like infections by multidrug-resistant organisms and Clostridioides difficile. Other biomarkers, such as C-reactive protein and presepsin, are already being tested as guidance for shorter antimicrobial treatment, but more research is needed. Current evidence suggests that biomarkers, mainly procalcitonin, should be implemented in antimicrobial stewardship programs even in the COVID-19 era, when, although bacterial coinfection rate is low, antimicrobial overconsumption remains high.

Antibiotics duration guided by biomarkers in hospitalized adult patients; a systematic review and meta-analysis

BACKGROUND

The impact of using biomarkers to determine the duration of antibiotics therapy has been studied. However, the question remains in clinical practice whether these biomarkers are reliable to determine antibiotics duration.

AIM

This study is aimed to see if employing c-reactive protein (CRP) and Procalcitonin (PCT) to determine the duration of antibiotic use in hospitalized adult patients is both effective and safe.

METHODS

Search databases that were used are Pubmed, Cochrane library, and Embase. Only randomized controlled trials conducted in adult (≥18 years) hospitalized patients were included. The primary outcome assessed is the duration of antibiotics used. Secondary outcomes assessed are the length of hospitalization, recurrence of infection/rehospitalization, in-hospital mortality, and 28-day mortality.

RESULTS

For the primary outcome, which is the duration of antibiotics use, PCT guided therapy significantly decreased the duration of antibiotics used in both sepsis and respiratory tract infections. For the secondary outcomes, there was no statistically significant difference in the outcomes of length of hospitalization, recurrence of infection/rehospitalization, and 28-day mortality. However, in-hospital mortality was significantly reduced (p = .02). CRP guided reduced antibiotic use duration, but there was no statistically significant difference in other outcomes including length of hospital stay, 28-day mortality, and infection recurrence.

CONCLUSION

Procalcitonin-guided antibiotics therapy was shown to be effective and safe in the reduction of antibiotics duration in both sepsis and respiratory tract infections. More research is needed to prove that CRP-guided therapy is safe and effective to determine the antibiotic duration in adult hospitalized patients.

REVIEW REGISTRATION NUMBER

PROSPERO (CRD42021264167).

Impact of a Procalcitonin-Based Protocol on Antibiotic Exposure and Costs in Critically Ill Patients

Supplemental Digital Content is available in the text.

To examine the impact before and after adoption of a procalcitonin-based protocol to guide sepsis management has on antibiotic use, care costs, and outcomes of critically ill patients.

Procalcitonin for individualizing antibiotic treatment: an update with a focus on COVID-19

Procalcitonin (PCT) is useful for differentiating between viral and bacterial infections and for reducing the unnecessary use of antibiotics. As the rise of antimicrobial resistance reaches “alarming” levels according to the World Health Organization, the importance of using biomarkers, such as PCT to limit unnecessary antibiotic exposure has further increased. Randomized trials in patients with respiratory tract infections have shown that PCT has prognostic implications and its use, embedded in stewardship protocols, leads to reductions in the use of antibiotics in different clinical settings without compromising clinical outcomes. However, available data are heterogeneous and recent trials found no significant benefit. Still, from these trials, we have learned several key considerations for the optimal use of PCT, which depend on the clinical setting, severity of presentation, and pretest probability for bacterial infection. For patients with respiratory infections and sepsis, PCT can be used to determine whether to initiate antimicrobial therapy in low-risk settings and, together with clinical data, whether to discontinue antimicrobial therapy in certain high-risk settings. There is also increasing evidence regarding PCT-guided therapy in patients with coronavirus disease 2019 (COVID-19). This review provides an up-to-date overview of the use of PCT in different clinical settings and diseases, including a discussion about its potential to improve the care of patients with COVID-19.

Biomarkers in sepsis: can they help improve patient outcome?

PURPOSE OF REVIEW

Biomarkers, mainly procalcitonin, are commonly used in sepsis diagnosis, prognosis and treatment follow-up. This review summarizes the potential benefit of their use for the critically ill.

RECENT FINDINGS

Increased clinical evidence from randomized clinical trials of biomarker-guided treatment suggests a trend for appropriate but short antimicrobial treatment for the critically ill. Procalcitonin (PCT) is the most studied biomarker; in the majority of randomized clinical trials, the use of a stopping rule of antibiotics on the day when PCT is below 80% from baseline or less than 0.5 ng/ml was proven effective to reduce length of antimicrobial treatment, antibiotic-associated adverse events and infectious complications like infections by multidrug-resistant organisms and Clostridium difficile. Survival benefit was also noted.

SUMMARY

Biomarkers, mainly PCT, may help improve sepsis outcome by restriction of injudicious antimicrobial use.

Clinical impact of procalcitonin-based algorithms for duration of antibiotic treatment in critically ill adult patients with sepsis: a meta-analysis of randomized clinical trials

Background: Our objective was to assess the impact on mortality, antibacterial therapy duration, and length of stay of using PCT to guide antibiotic cessation in critically ill patients with sepsis or septic shock.Research design and Methods: A systematic literature search was performed in PubMed, Embase, ISI Web of Knowledge, BioMed Central, ScienceDirect and the Cochrane Central Register of Controlled Trials, of clinical trials published in English before December 31, 2019. Eligible studies should be carried out in adults at ICU with sepsis, comparing the PCT-guided antimicrobial therapy with standard of care. A random effects model was used.Results: Twelve studies were eligible with a total of 4292 patients included. The combined relative risk for 28-day mortality was 0.89 (95% CI: 0.79; 0.99), for the duration of antimicrobial therapy was -1.98 days (95% CI: -2.76, -1.21) and for ICU- length of stay was-1.21 days (95% CI: -4.16, 1.74).Conclusions: In critically ill adults with sepsis, a procalcitonin-guided strategy is associated with a significant shorter duration of antimicrobial therapy. This reduction was associated with a significant decrease in mortality although the length of ICU stay was not affected.

Evaluation of the necessity and the feasibility of the standardization of procalcitonin measurements: Activities of IFCC WG-PCT with involvement of all stakeholders

Procalcitonin (PCT) is an important biomarker for sepsis diagnosis and management. To date, there is no higher-order reference measurement procedure (RMP) and certified reference material to achieve global standardization of results and results traceability to the SI units. Although efforts have been made to harmonize PCT results, a number of comparison studies and external quality assessment (EQA) schemes show conflicting results regarding results comparability and to date, equivalence of PCT results across the assays remains questionable in absence of studies relying on commutable EQA materials. In this context, the IFCC initiated activities to fill these gaps through the creation of the working group on standardization of PCT assays that gathers experts from National Metrology Institutes, calibration laboratories, clinicians, biologists, EQA providers and assay manufacturers. Among the activities, a higher order RMP and commutable reference materials are under development to build a robust reference measurement system (RMS). A commutability study is being organized to identify EQA materials that are fit for purpose to reliably estimate the current comparability of PCT results. This work will make it possible to evaluate the necessity and the feasibility for establishing and maintaining a new RMS for PCT assays, if deemed necessary.

The value of biomarker-guided antibiotic therapy

INTRODUCTION

There is an increasing interest to individualize patient management and decisions regarding antibiotic treatment. Biomarkers may provide relevant information for this purpose.

AREAS COVERED

Despite a growing number of clinical trials investigating several biomarkers, there remain open questions regarding the best type of biomarker, timing or frequency of testing, and optimal cutoffs among others. The most promising results in regard to diagnosis of bacterial infection and therapy monitoring are found for procalcitonin (PCT), although some recent trials were not able to validate the promising earlier findings. Furthermore, less specific markers like C-reactive protein (CRP) and new prognostic biomarkers such as proadrenomedullin (MR-proADM) may improve the prognostic assessment of patients and proteomics may help shorten time to microbiological results. The aim of this review is to summarize the current concept of biomarker-guided management and provide an outlook of promising ongoing investigations.

EXPERT OPINION

'Antibiotic stewardship' is complex and needs more than just the measurement of one single biomarker. However, when integrated into the context of a thorough clinical examination, standard blood parameters and a well done risk stratification by clinical scores such as the SOFA-score, biomarkers have great potential to improve the diagnostic and prognostic assessment of patients.

A 2020 review on the role of procalcitonin in different clinical settings: an update conducted with the tools of the Evidence Based Laboratory Medicine

Biomarkers to guide antibiotic treatment decisions have been proposed as an effective way to enhancing a more appropriate use of antibiotics. As a biomarker, procalcitonin (PCT) has been found to have good specificity to distinguish bacterial from non-bacterial inflammations. Decisions regarding antibiotic use in an individual patient are complex and should be based on the pre-test probability for bacterial infection, the severity of presentation and the results of PCT serum concentration. In the context of a high pre-test probability for bacterial infections and/or a high-risk patient with sepsis, monitoring of PCT over time helps to track the resolution of infection and decisions regarding early stop of antibiotic treatment. As outlined by the Evidence Based Laboratory Medicine (EBLM), not only the pre-test probability but also the positive likelihood ratio influence the performance of a test do be really diagnostic. This aspect should be taken into account in the interpretation of the results of clinical trials evaluating the performance of PCT in guiding antibiotic therapy.

The use of procalcitonin for the management of sepsis in Internal Medicine wards: current evidence

Procalcitonin (PCT) is a circulating polypeptide produced in response to bacterial infections. Studies conducted in the Intensive Care Unit (ICU) setting have demonstrated its utility as a biomarker of bacterial infection and sepsis. Thus, PCT is widely used to distinguish between sepsis and SIRS, and to guide antibiotic therapy. At present sepsis represents a frequent diagnosis among patients admitted to internal medicine (IM) departments. Basing on the knowledge derived from ICU studies, the use of PCT has become routine in non-intensive wards, contributing to improve the management of sepsis. However, some differences between the two populations of patients - the IM being older, affected by multiple chronic comorbidities and lacking of invasive monitoring - could limit the generalizability of ICU results. Most of the studies on PCT conducted in the IM setting have focused on chronic obstructive pulmonary disease, pneumonia and sepsis. Although PCT represents one of the best biomarker available in routine clinical practice, there are uncertainties on the optimal cut-offs to be used for starting or discontinuing antibiotic treatment in patients with suspected bacterial infection or sepsis, for predicting outcome and on the role of PCT variations during antibiotic treatment. Moreover, several diseases can produce an elevation of PCT levels, thus producing false positive results. This represents a narrative review summarizing current evidences on PCT for the management of sepsis in an Internal Medicine wards, highlighting differences with ICU, with a special focus on the role of PCT variations as predictor of outcomes in non-ICU wards.