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Procalcitonin-Based Guidelines and Lower Respiratory Tract Infections

Procalcitonin-Based Guidelines and Lower Respiratory Tract Infections To the Editor: In the study by Dr Schuetz and colleagues,1 the outcome of patients with LRTI and treatment guided by an algorithm based on PCT levels was similar to patients treated using internationally accepted guidelines. Major secondary end points were exposure to and prescription rate of antibiotics, which was lower in the PCT-guided group, including in patients with community-acquired pneumonia (CAP). It was concluded that PCT can play an important role in the therapeutic approach of LRTI, and that such an approach may reduce antibiotic use. Almost 50% of patients with CAP were classified with severe pneumonia (pneumonia severity index [PSI] classes IV-V). These patients were most likely admitted to the hospital and treated with antibiotics for a longer period, irrespective of the research strategy followed. In a previous study,2 patients with severe CAP had less of a reduction in antibiotic use from PCT guidance than patients with mild-to-moderate CAP (PSI classes I-III). Among patients with CAP in the study by Schuetz et al,1 it appears that antibiotic use reduction due to PCT guidance in patients was predominantly due to early stopping of antibiotic treatment, a mean reduction of approximately 3 days. The PCT test, performed at baseline, resulted in only a slightly lower prescription rate of antibiotics (91% vs 99% in the control group). In the control group, patients were frequently clinically evaluated, but no specific attempt was made to reduce the length of antibiotic treatment. In a meta-analysis,3 there was no difference in effectiveness and safety of short-course vs long-course antibiotic treatment in mild to moderate CAP. One of the pooled studies,4 which included patients with mild to moderate CAP, found that a 3-day amoxicillin treatment was not inferior to an 8-day treatment regimen. In the study by Schuetz et al,1 50% of the patients with CAP met the criteria for PSI classes I to III. We hypothesize that antibiotics could have been safely stopped in many of these patients after 3 days, irrespective of PCT levels. It would be of interest to know whether antibiotic use was also reduced in patients with severe CAP, and if adding a third study group with guidance based on clinical criteria had been considered. Back to top Article Information Financial Disclosures: None reported. References 1. Schuetz P, Christ-Crain M, Thomann R, et al; ProHOSP Study Group. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059-106619738090PubMedGoogle ScholarCrossref 2. Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174(1):84-9316603606PubMedGoogle ScholarCrossref 3. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia: a meta-analysis. Drugs. 2008;68(13):1841-185418729535PubMedGoogle ScholarCrossref 4. el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ. 2006;332(7554):135516763247PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Procalcitonin-Based Guidelines and Lower Respiratory Tract Infections

JAMA , Volume 303 (5) – Feb 3, 2010

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Publisher
American Medical Association
Copyright
Copyright © 2010 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2010.53
Publisher site
See Article on Publisher Site

Abstract

To the Editor: In the study by Dr Schuetz and colleagues,1 the outcome of patients with LRTI and treatment guided by an algorithm based on PCT levels was similar to patients treated using internationally accepted guidelines. Major secondary end points were exposure to and prescription rate of antibiotics, which was lower in the PCT-guided group, including in patients with community-acquired pneumonia (CAP). It was concluded that PCT can play an important role in the therapeutic approach of LRTI, and that such an approach may reduce antibiotic use. Almost 50% of patients with CAP were classified with severe pneumonia (pneumonia severity index [PSI] classes IV-V). These patients were most likely admitted to the hospital and treated with antibiotics for a longer period, irrespective of the research strategy followed. In a previous study,2 patients with severe CAP had less of a reduction in antibiotic use from PCT guidance than patients with mild-to-moderate CAP (PSI classes I-III). Among patients with CAP in the study by Schuetz et al,1 it appears that antibiotic use reduction due to PCT guidance in patients was predominantly due to early stopping of antibiotic treatment, a mean reduction of approximately 3 days. The PCT test, performed at baseline, resulted in only a slightly lower prescription rate of antibiotics (91% vs 99% in the control group). In the control group, patients were frequently clinically evaluated, but no specific attempt was made to reduce the length of antibiotic treatment. In a meta-analysis,3 there was no difference in effectiveness and safety of short-course vs long-course antibiotic treatment in mild to moderate CAP. One of the pooled studies,4 which included patients with mild to moderate CAP, found that a 3-day amoxicillin treatment was not inferior to an 8-day treatment regimen. In the study by Schuetz et al,1 50% of the patients with CAP met the criteria for PSI classes I to III. We hypothesize that antibiotics could have been safely stopped in many of these patients after 3 days, irrespective of PCT levels. It would be of interest to know whether antibiotic use was also reduced in patients with severe CAP, and if adding a third study group with guidance based on clinical criteria had been considered. Back to top Article Information Financial Disclosures: None reported. References 1. Schuetz P, Christ-Crain M, Thomann R, et al; ProHOSP Study Group. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059-106619738090PubMedGoogle ScholarCrossref 2. Christ-Crain M, Stolz D, Bingisser R, et al. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial. Am J Respir Crit Care Med. 2006;174(1):84-9316603606PubMedGoogle ScholarCrossref 3. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia: a meta-analysis. Drugs. 2008;68(13):1841-185418729535PubMedGoogle ScholarCrossref 4. el Moussaoui R, de Borgie CA, van den Broek P, et al. Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. BMJ. 2006;332(7554):135516763247PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Feb 3, 2010

References