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Procalcitonin Guidance of Antibiotic Therapy in Community-acquired Pneumonia

A Randomized Trial

Departments of Internal Medicine, Endocrinology, Pneumology, Emergency Medicine, and Clinical Chemistry, University Hospital, Basel; Medical University Clinic, Kantonsspital, Liestal; and Division of Hospital Epidemiology, University Hospital, Geneva, Switzerland

Correspondence and requests for reprints should be addressed to Mirjam Christ-Crain, M.D., University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland. E-mail: christmj{at}bluewin.ch

Rationale: In patients with community-acquired pneumonia, guidelines recommend antibiotic treatment for 7 to 21 d. Procalcitonin is elevated in bacterial infections, and its dynamics have prognostic implications.

Objective: To assess procalcitonin guidance for the initiation and duration of antibiotic therapy in community-acquired pneumonia.

Methods: In a randomized intervention trial, 302 consecutive patients with suspected community-acquired pneumonia were included. Data were assessed at baseline, after 4, 6, and 8 d, and after 6 wk.

The control group (n = 151) received antibiotics according to usual practice. In the procalcitonin group (n = 151), antibiotic treatment was based on serum procalcitonin concentrations as follows: strongly discouraged, less than 0.1 µg/L; discouraged, less than 0.25 µg/L; encouraged, greater than 0.25 µg/L; strongly encouraged, greater than 0.5 µg/L. The primary endpoint was antibiotic use; secondary endpoints were measures of clinical, laboratory, and radiographic outcome.

Results: At baseline, both groups were similar regarding clinical, laboratory, and microbiology characteristics, and Pneumonia Severity Index. Procalcitonin guidance reduced total antibiotic exposure (relative risk, 0.52; 95% confidence interval, 0.48–0.55; p < 0.001), antibiotic prescriptions on admission (85 vs. 99%; p < 0.001), and antibiotic treatment duration (median, 5 vs. 12 d; p < 0.001) compared with patients treated according to guidelines. After adjustment for Pneumonia Severity Index, the hazard ratio of antibiotic discontinuation was higher in the procalcitonin group than in the control group (3.2; 95% confidence interval, 2.5 to 4.2). Outcome was similar in both groups, with an overall success rate of 83%.

Conclusions: Procalcitonin guidance substantially reduces antibiotic use in community-acquired pneumonia. These findings may have important clinical and public health implications.

Key Words: antibiotic therapy • community-acquired pneumonia • procalcitonin

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