Meta-analysis and systematic review of procalcitonin-guided therapy in respiratory tract infections

Abstract

Circulating procalcitonin (PCT) is a biomarker that can be used in diagnosing bacterial infections. We performed a quantitative meta-analysis of available randomized controlled trials to determine whether antibiotic therapy based on PCT measurements alters clinical outcomes and antibiotic use in patients with lower respiratory tract infections. We identified studies through MEDLINE (1996 to 2010), the ISI Web of Knowledge (1996 to 2010), and Ovid. Studies that met our criteria were prospective, randomized controlled trials involving patients with respiratory tract infections. Outcomes of mortality, intensive care unit (ICU) admission, length of hospital stay, number of antibiotic prescriptions, and duration of antibiotic treatment were evaluated. Eight studies randomizing 3,431 patients met our criteria for inclusion. Pooled analysis showed a significant reduction in number of antibiotic prescriptions and duration of antibiotic use in patients with PCT-guided antibiotic treatment compared to standard therapy. In addition, the use of PCT-guided antibiotic therapy did not impact mortality, ICU admission, or length of hospital stay in these studies. A high degree of heterogeneity was identified in 3 of 5 outcomes that were evaluated, and sensitivity analysis indicated that heterogeneity was decreased among studies using the same PCT-based treatment algorithm. In conclusion, PCT-guided antibiotic therapy in patients with respiratory tract infections appears to reduce antibiotic use without affecting overall mortality or length of stay in the hospital.

Fig. 1.

Comparison of all-cause mortality between the PCT-guided antibiotic group and the control group. Test for heterogeneity: χ² = 1.51, P = 0.912, and I² = 0.0%. Test for overall effect: RR = 0.998, z = 0.24, and P = 0.809.

Fig. 2.

Comparison of overall ICU admissions between patients receiving PCT-guided antibiotic therapy and those receiving standard antibiotic therapy. Test for heterogeneity: χ² = 1.31, P = 0.727, and I² = 0.0%. Test for overall effect: RR = 0.785, z = 1.50, and P = 0.132.

Fig. 3.

Forest plot for the weighted mean difference in length of hospital stay. Test for heterogeneity: χ² = 100.20, P < 0.001, and I² = 95%. Test for overall effect: standardized mean difference (SMD) = −0.355, z = 1.66, and P = 0.097.

Fig. 4.

Forest plot for odds ratio of antibiotic prescriptions in PCT-guided antibiotic treatment groups and control groups. Test for heterogeneity: χ² = 192.34, P < 0.001, and I² = 96.9%. Test for overall effect: RR = 0.692, z = 3.01, and P = 0.03.

Fig. 5.

Forest plot for the weighted mean difference of duration of antibiotic use. Test for heterogeneity: χ² = 327.75, P < 0.001, and I² = 98.2%. Test for overall effect: SMD = −1.272, z = 4.23, and P < 0.001.