Reference : Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections
Scientific journals : Article
Human health sciences : Anesthesia & intensive care
http://hdl.handle.net/2268/218434
Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections
English
Schuetz, Philipp [Kantonsspital Aarau, Medical University Department, Aarau, Switzerland, Kantonsspital Aarau, Department of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal Medicine, Aarau, Switzerland, University of Basel, Medical Faculty, Basel, Switzerland]
Wirz, Yannick [Kantonsspital Aarau, Medical University Department, Aarau, Switzerland]
Sager, R. [Kantonsspital Aarau, Medical University Department, Aarau, Switzerland]
Christ-Crain, M. [University Hospital Basel, University of Basel, Clinic for Endocrinology, Diabetes and Metabolism, Department of Clinical Research, Petersgraben 4, Basel, Switzerland]
Stolz, D. [University Hospital Basel, Clinic of Pneumology and Pulmonary Cell Research, Petersgraben 4, Basel, Switzerland]
Tamm, M. [University Hospital Basel, Clinic of Pneumology and Pulmonary Cell Research, Petersgraben 4, Basel, Switzerland]
Bouadma, L. [Hôpital Bichat-Claude Bernard, Université Paris 7-Denis-Diderot, Service de Réanimation Médicale, Paris, France]
Luyt, C. E. [Groupe Hospitalier Pitie-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Paris 6-Pierre-et-Marie-Curie, Service de Réanimation Médicale, Paris, France]
Wolff, M. [Université Paris 7-Denis-Diderot, Service de Réanimation Médicale, Hôpital Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France]
Chastre, J. [Université Paris 6-Pierre-et-Marie-Curie, Service de Réanimation Médicale, Hôpital PitiéSalpêtrière (AP-HP), Paris, France]
Tubach, F. [Sante Publique et Information Medicale, AP-HP, Groupe Hospitalier Pitie-Salpetriere Charles-Foix, INSERM CIC-P 1421, Sorbonne Universités, UPMC Univ Paris 06, Département Biostatistique, Paris, France]
Kristoffersen, K. B. [Aarhus University Hospital, Department of Infectious Diseases, Skejby, Brendstrupgaardvej 100, Aarhus N, Denmark]
Burkhardt, O. [Medizinische Hochschule Hannover, Department of Pulmonary Medicine, Carl-Neuberg-Str. 1, Hannover, Niedersachsen, Germany]
Welte, T. [Medizinische Hochschule Hannover, Department of Pulmonary Medicine, Carl-Neuberg-Str. 1, Hannover, Niedersachsen, Germany, German Center for Lung Reearch (DZL), Aulweg 130, Gießen, Germany]
Schroeder, S. [Krankenhaus Dueren, Department of Anesthesiology and Intensive Care Medicine, Dueren, Germany]
Nobre, V. [Universidade Federal de Minas Gerais, Department of Internal Medicine, School of Medicine, Minas Gerais, Belo Horizonte, Brazil]
Wei, L. [Shanghai Jiao Tong University Affiliated Sixth People's Hospital (East campus), Department of Internal and Geriatric Medicine, Shanghai, China]
Bucher, H. C. [University Hospital Basel, Medical Faculty, Basel, Switzerland, University Hospital Basel and University of Basel, Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, Petersgraben 4, Basel, Switzerland]
Bhatnagar, N. [McMaster University, Department of Clinical Epidemiology and Biostatistics, 1200 Main Street West, Hamilton, ON, Canada]
Annane, D. [Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, and Université Versailles - Pari Saclay, Critical Care Department, 104. Boulevard Raymond Poincaré, Garches, Ile de France, France]
Reinhart, K. [Jena University Hospital, Department of Anesthesiology and Intensive Care Medicine, Erlanger Allee 101, Jena, Germany]
Branche, A. [University of Rochester School of Medicine, Department of Medicine, Division of Infectious Diseases, Rochester, NY, United States]
Damas, Pierre mailto [Université de Liège - ULiège > Département des sciences cliniques > Anesthésie et réanimation >]
Nijsten, M. [University of Groningen, University Medical Centre, Groningen, Netherlands]
de Lange, D. W. [University Medical Center Utrecht, Department of Intensive Care, Heidelberglaan 100, Utrecht, Netherlands]
Deliberato, R. O. [Hospital Israelita Albert Einstein, Critical Care Unit, São Paulo, Brazil]
Lima, S. S. [Universidade Federal de Minas Gerais, Graduate Program in Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of Medicine, Belo Horizonte, Brazil]
Maravić-Stojković, V. [Dedinje Cardiovascular Institute, Immunology Laboratory, Belgrade, Serbia]
Verduri, A. [University of Modena and Reggio Emilia, Department of Medical and Surgical Sciences, Policlinico di Modena, Modena, Italy]
Cao, B. [China-Japan Friendship Hospital, National Clinical Research Center of Respiratory Diseases, Capital Medical University, Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, Beijing, China]
Shehabi, Y. [Monash Health, Critical Care and Peri-operative Medicine, Melbourne, VIC, Australia, Monash University, School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Melbourne, VIC, Australia]
Beishuizen, A. [Medisch Spectrum Twente, Department of Intensive Care, Enschede, Netherlands]
Jensen, J.-U. S. [Rigshospitalet, University of Copenhagen, CHIP, Department of Infectious Diseases and Rheumatology, Finsencentret, Blegdamsvej 9, DK-2100, Copenhagen, Denmark, Copenhagen University Hospital, Bispebjerg og Frederiksberg, Department of Respiratory Medicine, Bispebjerg Bakke, Copenhagen NV, Capitol Region, Denmark]
Corti, C. [Copenhagen University Hospital, Bispebjerg og Frederiksberg, Department of Respiratory Medicine, Bispebjerg Bakke, Copenhagen NV, Capitol Region, Denmark]
Van Oers, J. A. [Elisabeth Tweesteden Ziekenhuis, Intensive Care Unit, Tilburg, Netherlands]
Falsey, A. R. [University of Rochester School of Medicine, Department of Medicine, Division of Infectious Diseases, Rochester, NY, United States]
de Jong, E. [VU University Medical Center, Department of Intensive Care, Amsterdam, Netherlands]
Oliveira, C. F. [Federal University of Minas Gerais, Department of Internal Medicine, School of Medcine, Belo Horizonte, Brazil]
Beghe, B. [AOU Policlinico di Modena, Department of Medical and Surgical Sciences, Moderna, Italy]
Briel, M. [University of Basel, Medical Faculty, Basel, Switzerland, University Hospital Basel and University of Basel, Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, Petersgraben 4, Basel, Switzerland]
Mueller, B. [Kantonsspital Aarau, Medical University Department, Aarau, Switzerland, Kantonsspital Aarau, Department of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal Medicine, Aarau, Switzerland, University of Basel, Medical Faculty, Basel, Switzerland]
2017
Cochrane Database of Systematic Reviews
John Wiley and Sons Ltd
2017
10
Yes
1469-493X
[en] Review
[en] Background: Acute respiratory infections (ARIs) comprise of a large and heterogeneous group of infections including bacterial, viral, and other aetiologies. In recent years, procalcitonin (PCT), a blood marker for bacterial infections, has emerged as a promising tool to improve decisions about antibiotic therapy (PCT-guided antibiotic therapy). Several randomised controlled trials (RCTs) have demonstrated the feasibility of using procalcitonin for starting and stopping antibiotics in different patient populations with ARIs and different settings ranging from primary care settings to emergency departments, hospital wards, and intensive care units. However, the effect of using procalcitonin on clinical outcomes is unclear. This is an update of a Cochrane review and individual participant data meta-analysis first published in 2012 designed to look at the safety of PCT-guided antibiotic stewardship. Objectives: The aim of this systematic review based on individual participant data was to assess the safety and efficacy of using procalcitonin for starting or stopping antibiotics over a large range of patients with varying severity of ARIs and from different clinical settings. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, and Embase, in February 2017, to identify suitable trials. We also searched ClinicalTrials.gov to identify ongoing trials in April 2017. Selection criteria: We included RCTs of adult participants with ARIs who received an antibiotic treatment either based on a procalcitonin algorithm (PCT-guided antibiotic stewardship algorithm) or usual care. We excluded trials if they focused exclusively on children or used procalcitonin for a purpose other than to guide initiation and duration of antibiotic treatment. Data collection and analysis: Two teams of review authors independently evaluated the methodology and extracted data from primary studies. The primary endpoints were all-cause mortality and treatment failure at 30 days, for which definitions were harmonised among trials. Secondary endpoints were antibiotic use, antibiotic-related side effects, and length of hospital stay. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable hierarchical logistic regression adjusted for age, gender, and clinical diagnosis using a fixed-effect model. The different trials were added as random-effects into the model. We conducted sensitivity analyses stratified by clinical setting and type of ARI. We also performed an aggregate data meta-analysis. Main results: From 32 eligible RCTs including 18 new trials for this 2017 update, we obtained individual participant data from 26 trials including 6708 participants, which we included in the main individual participant data meta-analysis. We did not obtain individual participant data for four trials, and two trials did not include people with confirmed ARIs. According to GRADE, the quality of the evidence was high for the outcomes mortality and antibiotic exposure, and quality was moderate for the outcomes treatment failure and antibiotic-related side effects. Primary endpoints: there were 286 deaths in 3336 procalcitonin-guided participants (8.6%) compared to 336 in 3372 controls (10.0%), resulting in a significantly lower mortality associated with procalcitonin-guided therapy (adjusted OR 0.83, 95% CI 0.70 to 0.99, P = 0.037). We could not estimate mortality in primary care trials because only one death was reported in a control group participant. Treatment failure was not significantly lower in procalcitonin-guided participants (23.0% versus 24.9% in the control group, adjusted OR 0.90, 95% CI 0.80 to 1.01, P = 0.068). Results were similar among subgroups by clinical setting and type of respiratory infection, with no evidence for effect modification (P for interaction > 0.05). Secondary endpoints: procalcitonin guidance was associated with a 2.4-day reduction in antibiotic exposure (5.7 versus 8.1 days, 95% CI -2.71 to -2.15, P < 0.001) and lower risk of antibiotic-related side effects (16.3% versus 22.1%, adjusted OR 0.68, 95% CI 0.57 to 0.82, P < 0.001). Length of hospital stay and intensive care unit stay were similar in both groups. A sensitivity aggregate-data analysis based on all 32 eligible trials showed similar results. Authors' conclusions: This updated meta-analysis of individual participant data from 12 countries shows that the use of procalcitonin to guide initiation and duration of antibiotic treatment results in lower risks of mortality, lower antibiotic consumption, and lower risk for antibiotic-related side effects. Results were similar for different clinical settings and types of ARIs, thus supporting the use of procalcitonin in the context of antibiotic stewardship in people with ARIs. Future high-quality research is needed to confirm the results in immunosuppressed patients and patients with non-respiratory infections. © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
http://hdl.handle.net/2268/218434
10.1002/14651858.CD007498.pub3

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