Schuetz Philipp, Kutz Alexander, Grolimund Eva, Haubitz Sebastian, Demann Désirée, Vögeli Alaadin, Hitz Fabienne, Christ-Crain Mirjam, Thomann Robert, Falconnier Claudine, Hoess Claus, Henzen Christoph, Marlowe Robert J, Zimmerli Werner, Mueller Beat
University Department of Medicine, Kantonsspital Aarau, Switzerland.
University Department of Medicine, Kantonsspital Aarau, Switzerland.
Int J Cardiol. 2014 Aug 20;175(3):464-72. doi: 10.1016/j.ijcard.2014.06.022. Epub 2014 Jun 27.
BACKGROUND/OBJECTIVES: We sought to determine whether exclusion of infection and antibiotic stewardship with the infection biomarker procalcitonin improves outcomes in congestive heart failure (CHF) patients presenting to emergency departments with respiratory symptoms and suspicion of respiratory infection.
We performed a secondary analysis of patients with a past medical history of CHF formerly included in a Swiss multicenter randomized-controlled trial. The trial compared antibiotic stewardship according to a procalcitonin algorithm or state-of-the-art guidelines (controls). The primary endpoint was a 30-day adverse outcome (death, intensive care unit admission); the secondary endpoints included a 30-day antibiotic exposure.
In the 110/233 analyzed patients (47.2%) with low initial procalcitonin (<0.25 μg/L), suggesting the absence of systemic bacterial infection, those randomized to procalcitonin guidance (n=50) had a significantly lower adverse outcome rate compared to controls (n=60): 4% vs. 20% (absolute difference -16.0%, 95% confidence interval (CI) -28.4% to -3.6%, P=0.01), and significantly reduced antibiotic exposure [days] (mean 3.7 ± 4.0 vs. 6.5 ± 4.4, difference -2.8 [95% CI, -4.4 to -1.2], P<0.01). When initial procalcitonin was ≥0.25 μg/L, procalcitonin-guided patients had significantly reduced antibiotic exposure due to early stop of therapy without any difference in adverse outcomes (25.8% vs. 24.6%, difference [95% CI] 1.2% [-14.5% to 16.9%, P=0.88]).
CHF patients presenting to the emergency department with respiratory symptoms and suspicion for respiratory infection had decreased antibiotic exposure and improved outcomes when procalcitonin measurement was used to exclude bacterial infection and guide antibiotic treatment. These data provide further evidence for the potential harmful effects of antibiotic / fluid treatment when used instead of diuretics and heart failure medication in clinically symptomatic CHF patients without underlying infection.
背景/目的：我们试图确定，使用感染生物标志物降钙素原排除感染并进行抗生素管理，是否能改善因呼吸道症状就诊于急诊科且疑似呼吸道感染的充血性心力衰竭（CHF）患者的预后。
我们对曾纳入一项瑞士多中心随机对照试验的有CHF病史的患者进行了二次分析。该试验比较了根据降钙素原算法进行的抗生素管理与现行指南（对照组）。主要终点是30天不良结局（死亡、入住重症监护病房）；次要终点包括30天抗生素暴露情况。
在110/233例（47.2%）初始降钙素原水平较低（<0.25μg/L）提示无全身性细菌感染的分析患者中，随机接受降钙素原指导的患者（n = 50）与对照组（n = 60）相比，不良结局发生率显著更低：4% 对20%（绝对差异 -16.0%，95%置信区间（CI）-28.4%至 -3.6%，P = 0.01），且抗生素暴露[天数]显著减少（平均3.7 ± 4.0对6.5 ± 4.4，差异 -2.8[95%CI，-4.4至 -1.2]，P<0.01）。当初始降钙素原≥0.25μg/L时，降钙素原指导组患者因治疗提前终止抗生素暴露显著减少，不良结局无差异（25.8%对24.6%，差异[95%CI]1.2%[-14.5%至16.9%，P = 0.88]）。
因呼吸道症状就诊于急诊科且疑似呼吸道感染的CHF患者中，使用降钙素原检测排除细菌感染并指导抗生素治疗时，抗生素暴露减少且预后改善。这些数据进一步证明，在无潜在感染的有临床症状的CHF患者中，使用抗生素/液体治疗而非利尿剂和心力衰竭药物可能产生有害影响。
