Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary.
Department of Anesthesiology and Intensive Therapy, Saint John's Hospital, Budapest, Hungary.
Crit Care. 2023 Oct 13;27(1):394. doi: 10.1186/s13054-023-04677-2.
Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients.
We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes.
We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively).
PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.
在重症监护病房（ICU）中，合理使用抗生素（AB）仍然是一个挑战。降钙素原（PCT）指导的 AB 管理有助于优化 AB 治疗并减少 AB 相关的不良反应，但仍缺乏确凿的证据。我们的目的是比较 PCT 指导的 AB 治疗与标准治疗（SOC）在危重病患者中的效果。
我们检索了 CENTRAL、Embase 和 Medline 数据库。我们纳入了比较 PCT 指导的 AB 治疗（PCT 组）与 SOC 并报告 AB 治疗时间、死亡率、复发和继发感染、ICU 住院时间（LOS）、住院时间或医疗保健费用的随机对照试验（RCT）。由于最近对脓毒症定义的改变，在应用 Sepsis-3 定义的研究中进行了亚组分析。在统计分析中，使用随机效应模型来汇总效应大小。
我们对 26 项 RCT（n=9048 例患者）进行了定量分析。与 SOC 相比，PCT 组 AB 治疗时间明显缩短（MD -1.79 天，95%CI：-2.65，-0.92），28 天死亡率明显降低（OR 0.84，95%CI：0.74，0.95）。在 Sepsis-3 患者中，死亡率获益更为显著（OR 0.46，95%CI：0.27，0.79）。PCT 组复发感染的几率明显更高（OR 1.36，95%CI：1.10，1.68），但继发感染的几率无显著差异（OR 0.81，95%CI：0.54，1.21），ICU 和住院时间也无显著差异（MD -0.67 天，95%CI：-1.76，0.41 和 MD -1.23 天，95%CI：-3.13，0.67）。
PCT 指导的 AB 治疗可能与 AB 使用减少、28 天死亡率降低但感染复发率升高相关，对 ICU 和住院时间没有影响。我们的结果表明，需要进行更好设计的研究来探讨 PCT 指导的 AB 管理在危重病患者中的作用。
