Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Crit Care Med. 2018 May;46(5):684-690. doi: 10.1097/CCM.0000000000002953.
Numerous studies have evaluated the use of procalcitonin guidance during different phases of antibiotics management (initiation, cessation, or a combination of both) in patients admitted to ICUs. Several meta-analyses have attempted to generate an overall effect of procalcitonin-guidance on patient outcomes. However, combining studies from different phases of antibiotics management may not be appropriate due to the risk of clinical heterogeneity. The purpose of this systematic review and meta-analysis was to evaluate the effect of procalcitonin-guided strategies in different phases of antibiotics use.
We searched MEDLINE and EMBASE from inception until November 1, 2017.
We included randomized controlled trials that evaluated procalcitonin guidance compared with usual care for management of antibiotics in critically ill adult patients.
We extracted study details, patient characteristics, procalcitonin algorithm, and outcomes.
We included 15 studies, from 1,624 abstracts identified based on our search strategy (three initiation, nine cessation, and three mixed). The pooled risk ratio for short-term mortality for the initiation, cessation, and mixed procalcitonin strategies were 1.00 (95% CI, 0.86-1.15,;p = 0.91), 0.87 (95% CI, 0.77-0.98; p = 0.02), and 1.01 (95% CI, 0.80-1.29; p = 0.93), respectively. Procalcitonin for cessation and mixed strategies was associated with decrease antibiotics duration (-1.26 d [p < 0.001] and -3.10 d [p =0.04], respectively). No differences were observed in other outcome measures.
When evaluating all studies of procalcitonin-guided antibiotics management in critically ill patients, no difference in short-term mortality was observed. However, when only examining procalcitonin-guided cessation of antibiotics, lower mortality was detected. Future studies should focus specifically on procalcitonin for the cessation of antibiotics in critically ill patients.
许多研究评估了降钙素原指导在 ICU 患者接受抗生素管理的不同阶段（启动、停止或两者结合）的使用情况。几项荟萃分析试图产生降钙素原指导对患者结局的总体影响。然而，由于临床异质性的风险，将来自不同抗生素管理阶段的研究合并在一起可能不合适。本系统评价和荟萃分析的目的是评估降钙素原指导策略在不同抗生素使用阶段的效果。
我们从 MEDLINE 和 EMBASE 数据库的建立开始搜索，一直持续到 2017 年 11 月 1 日。
我们纳入了评估降钙素原指导与常规护理对重症成年患者抗生素管理的随机对照试验。
我们提取了研究细节、患者特征、降钙素原算法和结局。
我们纳入了 15 项研究，这些研究来自于我们搜索策略确定的 1624 篇摘要（3 项启动、9 项停止和 3 项混合）。启动、停止和混合降钙素原策略的短期死亡率的汇总风险比分别为 1.00（95%CI，0.86-1.15，p=0.91）、0.87（95%CI，0.77-0.98，p=0.02）和 1.01（95%CI，0.80-1.29，p=0.93）。停止和混合策略中降钙素原与抗生素持续时间的缩短相关（分别减少 1.26 天（p<0.001）和 3.10 天（p=0.04））。其他结局指标无差异。
在评估所有关于重症患者降钙素原指导抗生素管理的研究时，未观察到短期死亡率的差异。然而，当仅观察降钙素原指导停止使用抗生素时，死亡率降低。未来的研究应特别关注降钙素原在重症患者停止使用抗生素方面的作用。
