Procalcitonin-guided Antibiotic Treatment in Patients With Positive Blood Cultures: A Patient-level Meta-analysis of Randomized Trials.

Marc A Meier, Angela Branche, Olivia L Neeser, Yannick Wirz, Sebastian Haubitz, Lila Bouadma, Michel Wolff, Charles E Luyt, Jean Chastre, Florence Tubach, Mirjam Christ-Crain, Caspar Corti, Jens-Ulrik S Jensen, Rodrigo O Deliberato, Kristina B Kristoffersen, Pierre Damas, Vandack Nobre, Carolina F Oliveira, Yahya Shehabi, Daiana Stolz, Michael Tamm, Beat Mueller, Philipp Schuetz

Journal: Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2020;69(3):388-396

PMID: 30358811

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Abstract

BACKGROUND

Whether procalcitonin (PCT)-guided antibiotic management in patients with positive blood cultures is safe remains understudied. We performed a patient-level meta-analysis to investigate effects of PCT-guided antibiotic management in patients with bacteremia.

METHODS

We extracted and analyzed individual data of 523 patients with positive blood cultures included in 13 trials, in which patients were randomly assigned to receive antibiotics based on PCT levels (PCT group) or a control group. The main efficacy endpoint was duration of antibiotic treatment. The main safety endpoint was mortality within 30 days.

RESULTS

Mean duration of antibiotic therapy was significantly shorter for 253 patients who received PCT-guided treatment than for 270 control patients (-2.86 days [95% confidence interval [CI], -4.88 to -.84]; P = .006). Mortality was similar in both arms (16.6% vs 20.0%; P = .263). In subgroup analyses by type of pathogen, we noted a trend of shorter mean antibiotic durations in the PCT arm for patients infected with gram-positive organisms or Escherichia coli and significantly shorter treatment for subjects with pneumococcal bacteremia. In analysis by site of infection, antibiotic exposure was shortened in PCT subjects with Streptococcus pneumoniae respiratory infection and those with E. coli urogenital infections.

CONCLUSIONS

This meta-analysis of patients with bacteremia receiving PCT-guided antibiotic management demonstrates lower antibiotic exposure without an apparent increase in mortality. Few differences were demonstrated in subgroup analysis stratified by type or site of infection but notable for decreased exposure in patients with pneumococcal pneumonia and E. coli urogenital infections.

Address: Medical University Department, Kantonsspital Aarau, Switzerland.; Department of Medicine, University of Rochester, Rochester General Hospital, New York.; Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), France.; Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, France.; Département d'Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, France.; Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Switzerland.; Department of Respiratory Medicine, Copenhagen University Hospital Bispebjerg, Denmark.; Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases and Rheumatology, Finsencentret, Rigshospitalet, University of Copenhagen, Denmark.; Department of Internal Medicine, Respiratory Medicine Section, Copenhagen University Hospital Herlev-Gentofte Hospital, Denmark.; Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.; Department of Infectious Diseases, Aarhus University Hospital, Denmark.; Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Belgium.; Department of Intensive Care, Hospital das Clinicas, Belo Horizonte, Brazil.; Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.; Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Victoria, Australia.; School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.; Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Switzerland.; Medical University Department, Kantonsspital Aarau, Switzerland.; Faculty of Medicine, University of Basel, Switzerland.

DOI: 10.1093/cid/ciy917

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MeSH Terms: Anti-Bacterial Agents, Antimicrobial Stewardship, Bacteremia, Biomarkers, Blood Culture, Disease Management, Escherichia coli, Escherichia coli Infections, Humans, Intensive Care Units, Pneumococcal Infections, Procalcitonin, Randomized Controlled Trials as Topic, Streptococcus pneumoniae