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Randomized Controlled Trial
. 2015 May 1:13:104.
doi: 10.1186/s12916-015-0347-y.

Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial

Daniel Drozdov  1   2 , Stefanie Schwarz  3 , Alexander Kutz  4 , Eva Grolimund  5 , Anna Christina Rast  6 , Deborah Steiner  7 , Katharina Regez  8 , Ursula Schild  9 , Merih Guglielmetti  10 , Antoinette Conca  11 , Barbara Reutlinger  12 , Cornelia Ottiger  13 , Florian Buchkremer  14 , Sebastian Haubitz  15 , Claudine Blum  16 , Andreas Huber  17 , Ulrich Buergi  18 , Philipp Schuetz  19 , Andreas Bock  20 , Christoph Andreas Fux  21 , Beat Mueller  22 , Werner Christian Albrich  23   24   25
Affiliations
Randomized Controlled Trial

Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial

Daniel Drozdov et al. BMC Med. .

Abstract

Background: Urinary tract infections (UTIs) are common drivers of antibiotic use. The minimal effective duration of antibiotic therapy for UTIs is unknown, but any reduction is important to diminish selection pressure for antibiotic resistance, costs, and drug-related side-effects. The aim of this study was to investigate whether an algorithm based on procalcitonin (PCT) and quantitative pyuria reduces antibiotic exposure.

Methods: From April 2012 to March 2014, we conducted a factorial design randomized controlled open-label trial. Immunocompetent adults with community-acquired non-catheter-related UTI were enrolled in the emergency department of a tertiary-care 600-bed hospital in northwestern Switzerland. Clinical presentation was used to guide initiation and duration of antibiotic therapy according to current guidelines (control group) or with a PCT-pyuria-based algorithm (PCT-pyuria group). The primary endpoint was overall antibiotic exposure within 90 days. Secondary endpoints included duration of the initial antibiotic therapy, persistent infection 7 days after end of therapy and 30 days after enrollment, recurrence and rehospitalizations within 90 days.

Results: Overall, 394 patients were screened, 228 met predefined exclusion criteria, 30 declined to participate, and 11 were not eligible. Of these, 125 (76% women) were enrolled in the intention-to-treat (ITT) analysis and 96 patients with microbiologically confirmed UTI constituted the per protocol group; 84 of 125 (67%) patients had a febrile UTI, 28 (22%) had bacteremia, 5 (4%) died, and 3 (2%) were lost to follow-up. Overall antibiotic exposure within 90 days was shorter in the PCT-pyuria group than in the control group (median 7.0 [IQR, 5.0-14.0] vs. 10.0 [IQR, 7.0-16.0] days, P = 0.011) in the ITT analysis. Mortality, rates of persistent infections, recurrences, and rehospitalizations were not different.

Conclusions: A PCT-pyuria-based algorithm reduced antibiotic exposure by 30% when compared to current guidelines without apparent negative effects on clinical outcomes.

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Figures

Figure 1
Figure 1
Algorithm for procalcitonin (PCT) and pyuria-guided therapy. TMP-SMX, Trimethoprim-sulfamethoxazole; NSAIDs, Non-steroidal anti-inflammatory drugs; eGFR, Estimated glomerular filtration rate with Modification of Diet in Renal Disease Study equation.
Figure 2
Figure 2
Flow diagram of patients in trial.
See this image and copyright information in PMC

References

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