Townsend Jennifer, Adams Victoria, Galiatsatos Panagis, Pearse David, Pantle Hardin, Masterson Mary, Kisuule Flora, Jacob Elsen, Kiruthi Catherine, Ortiz Paul, Agbanlog Albert, Jurao Robert, Stern Sam, Nayak Seema, Melgar Michael, Sama Jacob, Irwin Jillian, Mazidi Cyrus, Psoter Kevin, McKenzie Robin
Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
Open Forum Infect Dis. 2018 Dec 3;5(12):ofy327. doi: 10.1093/ofid/ofy327. eCollection 2018 Dec.
European trials using procalcitonin (PCT)-guided antibiotic therapy for patients with lower respiratory tract infections (LRTIs) have demonstrated significant reductions in antibiotic use without increasing adverse outcomes. Few studies have examined PCT for LRTIs in the United States.
In this study, we evaluated whether a PCT algorithm would reduce antibiotic exposure in patients with LRTI in a US hospital. We conducted a controlled pre-post trial comparing an intervention group of PCT-guided antibiotic therapy to a control group of usual care. Consecutive patients admitted to medicine services and receiving antibiotics for LRTI were enrolled in the intervention. Providers were encouraged to discontinue antibiotics according to a PCT algorithm. Control patients were similar patients admitted before the intervention.
The primary endpoint was median antibiotic duration. Overall adverse outcomes at 30 days comprised death, transfer to an intensive care unit, antibiotic side effects, infection, disease-specific complications, and post-discharge antibiotic prescription for LRTI. One hundred seventy-four intervention patients and 200 controls were enrolled. Providers complied with the PCT algorithm in 75% of encounters. Procalcitonin-guided therapy reduced median antibiotic duration for pneumonia from 7 days to 6 ( = .045) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) from 4 days to 3 ( = .01). There was no difference in the rate of adverse outcomes in the PCT and control groups.
A PCT-guided algorithm safely reduced the duration of antibiotics for treating LRTI. Utilization of a PCT algorithm may aid antibiotic stewardship efforts.This clinical trial was a single-center, controlled, pre-post study of PCT-guided antibiotic therapy for LRTI. The intervention (incorporation of PCT-guided algorithms) started on April 1, 2017: the preintervention (control group) comprised patients admitted from November 1, 2016 to April 16, 2017, and the postintervention group comprised patients admitted from April 17, 2017 to November 29, 2017 (Supplementary Figure 1). The study comprised patients admitted to the internal medicine services to a medical ward, the Medical Intensive Care Unit (MICU), the Cardiac Intensive Care Unit (CICU), or the Progressive Care Unit (PCU) "step down unit". The registration data for the trails are in the ClinicalTrials.gov database, number NCT0310910.
欧洲针对下呼吸道感染（LRTIs）患者采用降钙素原（PCT）指导抗生素治疗的试验表明，抗生素使用量显著减少，且未增加不良后果。在美国，很少有研究探讨PCT用于LRTIs的情况。
在本研究中，我们评估了PCT算法是否会减少美国一家医院LRTI患者的抗生素暴露。我们进行了一项前后对照试验，将PCT指导抗生素治疗的干预组与常规治疗的对照组进行比较。连续入住内科病房并因LRTI接受抗生素治疗的患者被纳入干预组。鼓励医疗服务提供者根据PCT算法停用抗生素。对照患者为干预前入院的类似患者。
主要终点是抗生素使用的中位数时长。30天的总体不良后果包括死亡、转入重症监护病房、抗生素副作用、感染、疾病特异性并发症以及出院后针对LRTI的抗生素处方。共纳入174例干预组患者和200例对照组患者。医疗服务提供者在75%的诊疗过程中遵循了PCT算法。PCT指导治疗将肺炎患者的抗生素使用中位数时长从7天降至6天（P = 0.045），慢性阻塞性肺疾病急性加重（AECOPD）患者从4天降至3天（P = 0.01）。PCT组和对照组的不良后果发生率无差异。
PCT指导算法安全地缩短了治疗LRTI的抗生素使用时长。采用PCT算法可能有助于抗生素管理工作。这项临床试验是一项针对LRTI的PCT指导抗生素治疗的单中心、对照、前后研究。干预（纳入PCT指导算法）于2017年4月1日开始：干预前（对照组）包括2016年11月1日至2017年4月16日入院的患者，干预后组包括2017年4月17日至2017年11月29日入院的患者（补充图1）。该研究包括入住内科病房、内科重症监护病房（MICU）、心脏重症监护病房（CICU）或逐步降级病房（PCU）“降级单元”的患者。该试验的注册数据存于ClinicalTrials.gov数据库，编号为NCT0310910。
