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Meta-Analysis
. 2018 Aug 15;22(1):191.
doi: 10.1186/s13054-018-2125-7.

Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials

Yannick Wirz  1 , Marc A Meier  1 , Lila Bouadma  2 , Charles E Luyt  3 , Michel Wolff  2 , Jean Chastre  3 , Florence Tubach  4 , Stefan Schroeder  5 , Vandack Nobre  6 , Djillali Annane  7 , Konrad Reinhart  8 , Pierre Damas  9 , Maarten Nijsten  10 , Arezoo Shajiei  10 , Dylan W deLange  11 , Rodrigo O Deliberato  12 , Carolina F Oliveira  13 , Yahya Shehabi  14   15 , Jos A H van Oers  16 , Albertus Beishuizen  17 , Armand R J Girbes  18 , Evelien de Jong  18 , Beat Mueller  1   19 , Philipp Schuetz  20   21
Affiliations
Meta-Analysis

Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials

Yannick Wirz et al. Crit Care. .

Abstract

Background: The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection.

Methods: For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the "procalcitonin-guided" group) or the current standard of care (the "controls"). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay.

Results: Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001).

Conclusion: Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.

Keywords: Antibiotic stewardship; Meta-analysis; Procalcitonin; Sepsis.

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Conflict of interest statement

Ethics approval and consent to participate

All trial included in the meta-analysis enrolled patients providing informed consent and had approval from their institutional review boards.

Consent for publication

Not applicable.

Competing interests

BioMérieux Inc. provided an unrestricted research grant to conduct this analysis. However, no personnel from the company were involved in the conduct of the analysis or in the preparation of the manuscript. PS and BM have received support from Thermo-Fisher and BioMérieux to attend meetings and fulfill speaking engagements. BM has also served as a consultant to BioMérieux and Thermo-Fisher. SS has received lecture fees and research support from Thermo-Fisher. CEL has received lecture fees from Brahms and Merck Sharp & Dohme-Chibret. JC has received consulting and lecture fees from Pfizer, Brahms, Wyeth, Johnson & Johnson, Nektar-Bayer, and Arpida. MW has received consulting and lectures fees from Merck Sharp & Dohme-Chibret, Janssen-Cilag, Gilead, Astellas, Sanofi, and Thermo-Fisher. YS has received unrestricted research grants from Thermo-fisher, BioMérieux, Orion Pharma, and Pfizer. The remaining authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Study flow diagram. ICU intensive care unit, PCT procalcitonin, RCT randomized controlled trial
Fig. 2
Fig. 2
Forest plot showing 30-day mortality. Association of procalcitonin (PCT)-guided antibiotic stewardship and mortality in predefined subgroups. CI confidence interval, CNS central nervous system, SOFA Sequential Organ Failure Assessment
See this image and copyright information in PMC

References

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