Procalcitonin-Guided Antibiotic Use vs a Standard Approach for Acute Respiratory Tract Infections in Primary Care | Infectious Diseases | JAMA Internal Medicine | JAMA Network
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1.
Goossens  HFerech  MVander  SRElseviers  M Outpatient antibiotic use in Europe and association with resistance: a cross-national database study.  Lancet 2005;365 (9459) 579- 587PubMedGoogle ScholarCrossref
2.
Gonzales  RMalone  DCMaselli  JHSande  MA Excessive antibiotic use for acute respiratory infections in the United States.  Clin Infect Dis 2001;33 (6) 757- 762PubMedGoogle ScholarCrossref
3.
Huchon  GJGialdroni-Grassi  GLeophonte  PManresa  FSchaberg  TWoodhead  M Initial antibiotic therapy for lower respiratory tract infection in the community: a European survey.  Eur Respir J 1996;9 (8) 1590- 1595PubMedGoogle ScholarCrossref
4.
Little  PGould  CWilliamson  IWarner  GGantley  MKinmonth  AL Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics.  BMJ 1997;315 (7104) 350- 352PubMedGoogle ScholarCrossref
5.
Mainous  AG  IIIHueston  WJ The cost of antibiotics in treating upper respiratory tract infections in a Medicaid population.  Arch Fam Med 1998;7 (1) 45- 49PubMedGoogle ScholarCrossref
6.
Hoare  ZLim  WS Pneumonia: update on diagnosis and management.  BMJ 2006;332 (7549) 1077- 1079PubMedGoogle ScholarCrossref
7.
van der Meer  VNeven  AKvan den Broek  PJAssendelft  WJ Diagnostic value of C reactive protein in infections of the lower respiratory tract: systematic review.  BMJ 2005;331 (7507) 26PubMedGoogle ScholarCrossref
8.
Gonzales  RCorbett  K The culture of antibiotics.  Am J Med 1999;107 (5) 525- 526PubMedGoogle ScholarCrossref
9.
Müller  BBecker  KLSchachinger  H  et al.  Calcitonin precursors are reliable markers of sepsis in a medical intensive care unit.  Crit Care Med 2000;28 (4) 977- 983PubMedGoogle ScholarCrossref
10.
Simon  LGauvin  FAmre  DKSaint-Louis  PLacroix  J Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis.  Clin Infect Dis 2004;39 (2) 206- 217PubMedGoogle ScholarCrossref
11.
Christ-Crain  MJaccard-Stolz  DBingisser  R  et al.  Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial.  Lancet 2004;363 (9409) 600- 607PubMedGoogle ScholarCrossref
12.
Christ-Crain  MStolz  DBingisser  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- 93PubMedGoogle ScholarCrossref
13.
Stolz  DChrist-Crain  MBingisser  R  et al.  Antibiotic treatment of exacerbations of COPD: a randomized, controlled trial comparing procalcitonin-guidance with standard therapy.  Chest 2007;131 (1) 9- 19PubMedGoogle ScholarCrossref
14.
Briel  MChrist-Crain  MYoung  J  et al.  Procalcitonin-guided antibiotic use versus a standard approach for acute respiratory tract infections in primary care: study protocol for a randomised controlled trial and baseline characteristics of participating general practitioners [ISRCTN73182671].  BMC Fam Pract 2005;634PubMedGoogle ScholarCrossref
15.
Piaggio  GElbourne  DRAltman  DGPocock  SJEvans  SJ Reporting of noninferiority and equivalence randomized trials: an extension of the CONSORT statement.  JAMA 2006;295 (10) 1152- 1160PubMedGoogle ScholarCrossref
16.
Gonzales  RBartlett  JGBesser  RE  et al.  Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods.  Ann Intern Med 2001;134 (6) 479- 486PubMedGoogle ScholarCrossref
17.
Hickner  JMBartlett  JGBesser  REGonzales  RHoffman  JRSande  MA Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background.  Ann Intern Med 2001;134 (6) 498- 505PubMedGoogle ScholarCrossref
18.
Cooper  RJHoffman  JRBartlett  JG  et al.  Principles of appropriate antibiotic use for acute pharyngitis in adults: background.  Ann Intern Med 2001;134 (6) 509- 517PubMedGoogle ScholarCrossref
19.
Snow  VLascher  SMottur-Pilson  C Evidence base for management of acute exacerbations of chronic obstructive pulmonary disease.  Ann Intern Med 2001;134 (7) 595- 599PubMedGoogle ScholarCrossref
20.
Bucher  HCBriel  MTschudi  P  et al.  Guidelines: Prinzipien der Diagnose und Behandlung von Infekten der Oberen Luftwege: PARTI Studie: Procalcitonin in Acute Respiratory Tract Infection Study: version 3. Basel Institute for Clinical Epidemiology Web site. http://www.bice.ch/cms/dyn_media/papers/files/Evidence_based_guidelines_for_acute_respiratory_tract_infections.PDF. Accessed August 20, 2008
21.
Snider  RH  JrNylen  ESBecker  KL Procalcitonin and its component peptides in systemic inflammation: immunochemical characterization.  J Investig Med 1997;45 (9) 552- 560Google Scholar
22.
Nylen  EMuller  BBecker  KLSnider  R The future diagnostic role of procalcitonin levels: the need for improved sensitivity.  Clin Infect Dis 2003;36 (6) 823- 824PubMedGoogle ScholarCrossref
23.
Briel  MLangewitz  WTschudi  PYoung  JHugenschmidt  CBucher  HC Communication training and antibiotic use in acute respiratory tract infections: a cluster randomised controlled trial in general practice.  Swiss Med Wkly 2006;136 (15-16) 241- 247PubMedGoogle Scholar
24.
Jones  BJarvis  PLewis  JAEbbutt  AF Trials to assess equivalence: the importance of rigorous methods.  BMJ 1996;313 (7048) 36- 39PubMedGoogle ScholarCrossref
25.
Pocock  SJAssmann  SEEnos  LEKasten  LE Subgroup analysis, covariate adjustment and baseline comparisons in clinical trial reporting: current practice and problems.  Stat Med 2002;21 (19) 2917- 2930PubMedGoogle ScholarCrossref
26.
Smucny  JFahey  TBecker  LGlazier  R Antibiotics for acute bronchitis.  Cochrane Database Syst Rev 2004; (4) CD000245PubMedGoogle Scholar
27.
Little  PRumsby  KKelly  J  et al.  Information leaflet and antibiotic prescribing strategies for acute lower respiratory tract infection: a randomized controlled trial.  JAMA 2005;293 (24) 3029- 3035PubMedGoogle ScholarCrossref
28.
Dowell  JPitkethly  MBain  JMartin  S A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care.  Br J Gen Pract 2001;51 (464) 200- 205PubMedGoogle Scholar
29.
Steinman  MAGonzales  RLinder  JALandefeld  CS Changing use of antibiotics in community-based outpatient practice, 1991-1999.  Ann Intern Med 2003;138 (7) 525- 533PubMedGoogle ScholarCrossref
30.
Filippini  MMasiero  GMoschetti  K Socioeconomic determinants of regional differences in outpatient antibiotic consumption: evidence from Switzerland.  Health Policy 2006;78 (1) 77- 92PubMedGoogle ScholarCrossref
31.
Stephenson  J Icelandic researchers are showing the way to bring down rates of antibiotic-resistant bacteria.  JAMA 1996;275 (3) 175PubMedGoogle ScholarCrossref
32.
Briel  MYoung  JTschudi  P  et al.  Prevalence and influence of diagnostic tests for acute respiratory tract infections in primary care.  Swiss Med Wkly 2006;136 (15-16) 248- 253PubMedGoogle Scholar
33.
Winkens  RDinant  GJ Evidence base of clinical diagnosis: rational, cost effective use of investigations in clinical practice.  BMJ 2002;324 (7340) 783PubMedGoogle ScholarCrossref
34.
Diederichsen  HZSkamling  MDiederichsen  A  et al.  Randomised controlled trial of CRP rapid test as a guide to treatment of respiratory infections in general practice.  Scand J Prim Health Care 2000;18 (1) 39- 43PubMedGoogle ScholarCrossref
Original Investigation
October 13, 2008

Procalcitonin-Guided Antibiotic Use vs a Standard Approach for Acute Respiratory Tract Infections in Primary Care

Author Affiliations

Author Affiliations: Department of Internal Medicine, Basel Institute for Clinical Epidemiology (Drs Briel, Young, and Bucher), Department of Internal Medicine, Clinic of Endocrinology, Diabetes, and Clinical Nutrition, (Drs Schuetz, Mueller, and Christ-Crain and Ms Schild), and Department of Chemical Pathology (Dr Nusbaumer), University Hospital Basel, Basel, Switzerland; and private general practice, Basel-Riehen, Switzerland (Dr Périat).

Arch Intern Med. 2008;168(18):2000-2007. doi:10.1001/archinte.168.18.2000
Abstract

Background  Acute respiratory tract infections are the most common reason for antibiotic therapy in primary care despite their mainly viral etiology. A laboratory test measuring procalcitonin levels in blood specimens was suggested as a tool to reduce unnecessary prescribing of antibiotics. We consider whether antibiotic therapy guided by procalcitonin reduces the use of antibiotics without increasing the restrictions experienced by patients by more than 1 day.

Methods  Fifty-three primary care physicians recruited 458 patients, each patient with an acute respiratory tract infection and, in the physician's opinion, in need of antibiotics. Patients were centrally randomized to either a procalcitonin-guided approach to antibiotic therapy or to a standard approach. For patients randomized to procalcitonin-guided therapy, the use of antibiotics was more or less strongly discouraged (procalcitonin level, ≤0.1 or ≤0.25 μg/L, respectively) or recommended (procalcitonin level, >0.25 μg/L). Follow-up data were collected at 7 days by treating physicians and at 14 and 28 days by blinded interviewers.

Results  Adjusted for baseline characteristics, the mean increase at 14 days in days in which activities were restricted was 0.14 with procalcitonin-guided therapy (95% confidence interval [CI], −0.53 to 0.81 days), which met our criterion of an increase in days in which activities were restricted by no more than 1 day. With procalcitonin-guided therapy, the antibiotic prescription rate was 72% lower (95% CI, 66%-78%) than with standard therapy. Both approaches led to a similar proportion of patients reporting symptoms of ongoing or relapsing infection at 28 days (adjusted odds ratio, 1.0 [95% CI, 0.7-1.5]).

Conclusions  As an adjunct to guidelines, procalcitonin-guided therapy markedly reduces antibiotic use for acute respiratory tract infections in primary care without compromising patient outcome. In practice, this could be achieved with 1 to 2 procalcitonin measurements in patients for whom the physician intends to prescribe antibiotics.

Trial Registration  isrctn.org Identifier: ISRCTN73182671

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