Procalcitonin-Guided Antibiotic Cessation Reduces Mortality in Critically Ill Patients

Since its discovery as a proven marker of an individual’s response to a bacterial infection, investigators have been actively pursuing how best to use the biomarker procalcitonin (PCT) to guide antibiotic therapy. Investigators have been researching the safety and efficacy of PCT-guided treatments for a multitude of infections, including acute respiratory infections. In fact, in early 2017, the US Food and Drug Administration cleared the expanded use of a PCT test to guide initiating or ceasing antibiotic treatment in patients with lower respiratory tract infections, and ceasing treatment in patients with sepsis.

Most meta-analyses of this research have looked at the combined the effects of PCT-guided therapy across all aspects of antibiotic management: initiation, cessation, or a combination of the 2; however, investigators from the Cleveland Clinic in Cleveland, Ohio and Sunnybrook Hospital, in Toronto, Ontario, took it a step further, instead performing a meta-analysis evaluating PCT-guided strategies during different phases of antibiotic management, focusing on the cessation of antibiotics stage. The research was recently presented at the 47th Critical Care Congress, which took place February 25 to 28, 2018, in San Antonio, Texas.

For the analysis, the investigators first performed a systematic review which identified “randomized control trials evaluating PCT compared to usual care for the management of antibiotic therapy in critically ill patients,” according to the abstract of the study. The primary outcome was determined to be short-term mortality (hospital mortality or mortality within 30 days.) The investigators set the secondary outcomes as duration of antibiotic therapy, long-term mortality (60 to 100 days), hospital and intensive care unit length of stay, and the presence of recurrent infections. A meta-analysis was performed for each outcome if the investigators found at least 3 studies in any of the PCT subgroups, thus having sufficient data. “Random or fixed effects models were used as appropriate,” the authors wrote.

A total of 1624 abstracts were identified, of which, 15 were included: 3 on using PCT to guide initiation of antibiotic therapy, 9 on using it to guide cessation of the therapy, and 3 on using a combination of the 2 strategies.

The results revealed that the pooled OR for short-term mortality for the initiation PCT strategy was 0.99 (95% CI: 0.81—1.22, P = .96)), 0.83 (95% CI: 0.70- 0.97, P = .02) for cessation PCT strategy; and 1.02 (95% CI: 0.72—1.43, P = .93) for a mix of the 2 PCT strategies. Using PCT for cessation of antibiotic therapies and the combination of strategies resulted in a decrease in antibiotic duration at -1.26 days, P<.001 and -3.10 days, P = .04, respectively. Differences were not observed for the secondary outcomes.

Although further research is needed that focuses specifically on PCT-guided antibiotic cessation in critically ill patients, this analysis revealed that the strategy resulted in reduced mortality in these patients.