Background:

• Antibiotics are prescribed commonly for URIs including acute bronchitis and community acquired pneumonia.
• Antibiotic prescriptions for non-bacterial causes of URIs lead to antibiotic overuse, which can lead to antibiotic resistance and risk of Clostridium difficile.
• Procalcitonin is a biomarker for bacterial infections and is released in response to bacterial toxins during infections.
• Several algorithms using procalcitonin have been developed to help guide antibiotic treatment of URIs based on blood levels and to aid discontinuing antibiotics when procalcitonin levels have returned to normal, leading to decreased use and length of antibiotic treatment courses.

Clinical Question:

• Does measurement of procalcitonin lead to shorter antibiotic exposure without increasing mortality and treatment failure?

Meta-analysis:

• 14 trials; 2004-11; 4211 patients with a variety of URI severity and type including CAP and COPD exacerbations.
• Inpatient and outpatient settings
• Compared to regular antibiotic treatment without procalcitonin level guidance.
• Primary outcomes: All cause mortality and treatment failure within 30 days.

Conclusions:

• No increase in all-cause mortality using procalcitonin algorithms versus standard therapy in any clinical setting or type of URI (5.7% vs. 6.3%, respectively).
• Treatment failure was LOWER for procalcitonin guided patients in the ED [OR 0.76 (95% CI, 0.61-0.95)].
• Lower antibiotic exposure due to lower prescription rate in COPD exacerbations and bronchitis.

Limitations:

•  Non-blinded to outcome assessment.
•  Adherence to algorithms was variable.
• Immunosuppressed patients and children were excluded.

Bottom Line:

• Another tool to help aid clinical decision making regarding antibiotic treatment
• Test is around $25-30 and takes about 1 hour to run
• Low levels may indicate a non-bacterial cause of infection.

References

Clinical Outcomes Associated With Procalcitonin Algorithms to Guide Antibiotic Therapy in Respiratory Tract Infections

Philipp Schuetz, MD, MPH; Matthias Briel, MD, MSc; Beat Mueller, MD

JAMA. 2013;309(7):717-718. doi:10.1001/jama.2013.697.

http://jama.jamanetwork.com/article.aspx?articleid=1653510