Department of Medicine, University of Rochester.
Department of Medicine, Rochester General Hospital, Rochester, New York, USA.
Curr Opin Infect Dis. 2019 Apr;32(2):130-135. doi: 10.1097/QCO.0000000000000522.
There is convincing evidence linking antibiotic-stewardship efforts which include the infection marker procalcitonin (PCT) to more rational use of antibiotics with improvements in side-effects and clinical outcomes. This is particularly true in the setting of respiratory infection and sepsis. Yet, some recent trials have shown no benefit of PCT-guided care. Our aim was to discuss the benefits and limitations of using PCT for early infection recognition, severity assessment and therapeutic decisions in individual patients based on most the recent study data.
Current evidence from randomized trials, and meta-analyses of these trials, indicates that PCT-guided antibiotic stewardship results in a reduction in antibiotic use and antibiotic side-effects, which translates into improved survival of patients with respiratory infections and sepsis. Notably, initial PCT levels have been found to be helpful in defining the risk for bacterial infection in the context of a low pretest probability for bacterial infections (i.e., patients with bronchitis or chronic bastructive pulmonary disease exacerbation). Monitoring of repeated PCT measurements over time has also been found helpful for estimating recovery from bacterial infection and prognosis in higher risk situations (i.e., pneumonia or sepsis) and results in early and safe discontinuation of antibiotic therapy. Some trials, however, did not find a strong effect of PCT guidance which may be explained by low protocol adherence, assessment using only a single rather than repeat PCT levels and lower antibiotic exposure in control group patients. Using PCT in the right patient population, with high-sensitivity assays and with adequate training of physicians is important to increase protocol adherence and reduce antibiotic exposure.
Inclusion of PCT into antibiotic stewardship algorithms has the potential to improve the diagnostic and therapeutic management of patients presenting with respiratory illnesses and sepsis, and holds great promise to mitigate the global bacterial resistance crisis and move from a default position of standardized care to more personalized treatment decisions.
有确凿的证据表明，抗生素管理措施（包括感染标志物降钙素原（PCT））与抗生素的合理使用有关，可以改善副作用和临床结果。这在呼吸道感染和败血症的情况下尤其如此。然而，一些最近的试验表明 PCT 指导护理没有益处。我们的目的是根据最近的研究数据，讨论在个体患者中使用 PCT 进行早期感染识别、严重程度评估和治疗决策的益处和局限性。
来自随机试验的现有证据以及对这些试验的荟萃分析表明，PCT 指导的抗生素管理可减少抗生素的使用和抗生素的副作用，从而提高呼吸道感染和败血症患者的生存率。值得注意的是，最初的 PCT 水平有助于在细菌感染的低前期可能性（即患有支气管炎或慢性阻塞性肺疾病加重的患者）背景下定义细菌感染的风险。随着时间的推移监测重复 PCT 测量也有助于估计从细菌感染中恢复和在高风险情况下（即肺炎或败血症）的预后，并导致早期和安全地停止抗生素治疗。然而，一些试验并没有发现 PCT 指导的强烈效果，这可能是由于低方案依从性、仅使用单次而不是重复 PCT 水平进行评估以及对照组患者的抗生素暴露较低所致。在正确的患者人群中使用 PCT，使用高灵敏度检测，并对医生进行充分培训，对于提高方案依从性和减少抗生素暴露非常重要。
将 PCT 纳入抗生素管理算法有可能改善患有呼吸道疾病和败血症的患者的诊断和治疗管理，并有望缓解全球细菌耐药危机，从标准化护理的默认立场转向更个性化的治疗决策。
