Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland.
Eur J Clin Microbiol Infect Dis. 2013 Jan;32(1):51-60. doi: 10.1007/s10096-012-1713-8. Epub 2012 Aug 12.
Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 μg/L and +31 % if PCT > 0.25 μg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 μg/L and +13 % if PCT > 0.25 μg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 μg/L and +19 % if PCT > 0.25 μg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.
降钙素原 (PCT) 指导的抗生素管理是降低抗生素使用的成功策略。我们评估了临床判断是否会影响多中心下呼吸道感染 (LRTI) 患者中抗生素使用的 PCT 算法的依从性。对连续入组的 LRTI 成年患者进行前瞻性观察性质量控制，监测抗生素治疗的起始和持续时间、对 PCT 算法的依从性以及结局。我们将治疗医生的初始临床判断与算法依从性相关联，并评估 PCT 对最终开始抗生素治疗的决定的影响。PCT 水平与医生对细菌感染可能性的估计相关 (p 趋势 <0.02)。PCT 对启动抗生素治疗的后验概率有影响，在非肺炎性 LRTI 患者中影响更大 (例如，如果 PCT ≤ 0.25 μg/L，则为 -23%；如果 PCT > 0.25 μg/L，则为 +31%)，在欧洲中心 (-22%如果 PCT ≤ 0.25 μg/L，+13%如果 PCT > 0.25 μg/L) 和具有 PCT 算法使用经验的中心 (-16%如果 PCT ≤ 0.25 μg/L，+19%如果 PCT > 0.25 μg/L)。尽管 PCT 水平较低，但仍开具抗生素的算法不依从，可独立预测为细菌感染的可能性由治疗医生判断。符合率与细菌病因的确定显著相关 (p = 0.01)。PCT 指导的抗生素管理的依从性受地理和文化影响的主观临床判断的影响。抗生素治疗的开始受到 PCT 水平的影响。抗生素管理依从性的差异导致抗生素处方习惯的地域差异，并可能影响抗生素耐药率。
