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Multicenter Study
. 2025 Nov;29(52):1-32.
doi: 10.3310/GGFF9393.

Procalcitonin evaluation of antibiotic use in COVID-19 hospitalised patients: The PEACH mixed methods study

Joanne Euden  1 , Mahableshwar Albur  2 , Rebecca Bestwick  3 , Stuart Bond  4 , Lucy Brookes-Howell  1 , Paul Dark  5 , Sarah Gerver  6 , Detelina Grozeva  1 , Ryan Hamilton  7   8 , Margaret Heginbothom  9 , Thomas Hellyer  10   11 , Josie Henley  12 , Russell Hope  6 , Susan Hopkins  6 , Philip Howard  13 , Daniel Howdon  3 , Natalie King  3 , Chikezie Knox-Macaulay  14 , Martin Llewelyn  15 , Wakunyambo Maboshe  1 , Iain McCullagh  10   11 , Margaret Ogden  14 , Philip Pallmann  1 , Helena Parsons  16 , David Partridge  16 , Neil Powell  17 , Graham Prestwich  14 , Colin Richman  18 , Dominick Shaw  19 , Bethany Shinkins  3   20 , Tamas Szakmany  21   22 , Emma Thomas-Jones  1 , Stacy Todd  23 , Edward Webb  3 , Robert West  3 , Enitan Carrol  24 , Jonathan Sandoe  25   26 ; PEACH Study Group
Affiliations
Multicenter Study

Procalcitonin evaluation of antibiotic use in COVID-19 hospitalised patients: The PEACH mixed methods study

Joanne Euden et al. Health Technol Assess. 2025 Nov.

Abstract

Background: Early in the COVID-19 pandemic, there was concern about potentially unnecessary antibiotic prescribing in the National Health Service. Procalcitonin testing was being used in some hospitals to guide antibiotic use. This study aimed to investigate the impact of procalcitonin testing on United Kingdom's antibiotic prescribing and health outcomes.

Methods: Mixed-methods study comprising quantitative, qualitative and health economic work packages, including a: survey of National Health Service hospitals to understand procalcitonin use retrospective, controlled, interrupted time series analysis of aggregated, organisation-level data, including antibiotic dispensing, hospital activity and procalcitonin testing from acute hospital trusts/hospitals in England/Wales. Primary outcome: change in level and/or trend of antibiotic prescribing rates following introduction of procalcitonin multicentre, retrospective, cohort study of 5960 patients using patient-level clinical data from 11 trusts/health boards to determine the difference in early antibiotic prescribing between COVID-19 patients who did/did not have baseline procalcitonin testing by using propensity score matching. Primary outcome: days of early antibiotic therapy qualitative study exploring the decision-making process around antibiotic use for inpatients with COVID-19 pneumonia to identify the contextual factors, feasibility and acceptability of procalcitonin testing algorithms health economic analysis evaluating the cost-effectiveness of baseline procalcitonin testing using the matched data within a decision-analytic model.

Setting: Acute hospital trusts/health boards in England/Wales.

Participants: Inpatients ≥ 16 years, admitted to participating trusts/health boards and with a confirmed positive COVID-19 test between 1 February 2020 and 30 June 2020, National Health Service healthcare workers.

Results: Early in the COVID-19 pandemic, procalcitonin use was expanded/introduced in many National Health Service hospitals, with variation in guidance and interpretation of results. The number of hospitals using procalcitonin in emergency/acute admissions rose from 17 (11%) to 74/146 (50.7%), and its use in intensive care unit increased from 70 (47.6%) to 124/147 (84.4%). Introduction of procalcitonin testing in emergency departments/acute medical admission units was associated with a statistically significant decrease in antibiotic use, which was not sustained. Patient-level data showed that baseline procalcitonin testing was associated with an average reduction in early antibiotic prescribing of 0.43 days (95% confidence interval: 0.22 to 0.64 days, p < 0.001) and a reduction of 0.72 days (95% confidence interval: 0.06 to 1.38 days, p = 0.03) in total antibiotic prescribing, with no increased mortality/hospital length of stay. Interviews revealed concerns about secondary bacterial infections that led to increased antibiotic prescribing in COVID-19 patients. As experience increased, clinician's ability to distinguish between COVID-19 alone and bacterial coinfections increased. Antibiotic prescribing decisions were influenced by factors such as senior support, situational factors and organisational influences. The health economic analysis concluded that baseline procalcitonin testing was more likely to be cost-effective than not, albeit with some uncertainty.

Conclusion: Baseline procalcitonin testing appears to have been an effective antimicrobial stewardship tool during the first wave of the pandemic, reducing antibiotic prescribing without evidence of harm.

Limitations: The retrospective, hospital record-based studies were limited by missing data, incorrectly recorded information and lack of randomisation. Interviews with clinicians were conducted more than a year after the first wave, potentially resulting in recall bias.

Future work: This study highlights the need for adaptive, inclusive, wide-reaching trials of infection diagnostics and implementation research to assess clinical utility before routine introduction into clinical practice.

Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132254.

Keywords: ANTIBIOTIC; ANTIMICROBIAL RESISTANCE; ANTIMICROBIAL STEWARDSHIP; COVID-19; DIAGNOSTIC STEWARDSHIP; INFLAMMATORY MARKERS; PCT; PROCALCITONIN.

Plain language summary

A blood test called procalcitonin is used in hospitals to help diagnose bacterial infections and guide antibiotic treatment decisions. There is evidence to support its use in lung infections. During the COVID-19 pandemic, some hospital clinicians used the procalcitonin test to guide antibiotic prescribing decisions, while in other hospitals, they did not. This study looked at how the procalcitonin test was used to help make those decisions and compared antibiotic prescribing and patient outcomes between hospitals that did or did not use the procalcitonin test. We asked hospital pharmacists to complete a survey on antibiotic prescribing, conducted interviews with clinicians who worked during the pandemic and collected and analysed data from patients’ clinical records from hospital trusts that did and did not use procalcitonin testing during the first wave of the COVID-19 pandemic. We showed how procalcitonin testing was used, how staff made decisions on antibiotic prescribing and how procalcitonin affected antibiotic use and patient outcomes. We found that procalcitonin was not used consistently across the National Health Survey. In hospitals that did use the test on patients with COVID-19, there was a statistically significant reduction in antibiotic prescribing, with no adverse effect on patient outcomes. We also found that antibiotic prescribing decisions for staff were influenced by many factors such as level of experience, confidence, support from other staff and internal organisational factors. Procalcitonin testing was likely to be value for money. Procalcitonin testing was shown to be a valid way to improve antibiotic use during the first wave of the pandemic. However, there remains a need for more adaptive, inclusive, wide-reaching clinical trials of tests that can diagnose infection. More implementation research is required before introduction into routine clinical practice.

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