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

被引：162

作者：

Wirz, Yannick ^{[1
]}

Meier, Marc A. ^{[1
]}

Bouadma, Lila ^{[3
]}

Luyt, Charles E. ^{[4
]}

Wolff, Michel ^{[3
]}

Chastre, Jean ^{[4
]}

Tubach, Florence ^{[5
]}

Schroeder, Stefan ^{[6
]}

Nobre, Vandack ^{[7
]}

Annane, Djillali ^{[8
]}

Reinhart, Konrad ^{[9
]}

Damas, Pierre ^{[10
]}

Nijsten, Maarten ^{[11
]}

Shajiei, Arezoo ^{[11
]}

deLange, Dylan W. ^{[12
]}

Deliberato, Rodrigo O. ^{[13
]}

Oliveira, Carolina F. ^{[14
]}

Shehabi, Yahya ^{[15
,16
]}

van Oers, Jos A. H. ^{[17
]}

Beishuizen, Albertus ^{[18
]}

Girbes, Armand R. J. ^{[19
]}

de Jong, Evelien ^{[19
]}

Mueller, Beat ^{[1
,2
]}

Schuetz, Philipp ^{[1
,2
]}

机构：

[1] Kantonsspital Aarau, Med Univ Dept, Tellstr, CH-5001 Aarau, Switzerland

[2] Univ Basel, Fac Med, Basel, Switzerland

[3] Univ Paris 07, AP HP, Serv Reanimat Med, Paris, France

[4] Univ Paris 6 Pierre & Marie Curie, Serv Reanimat Med, Paris, France

[5] Hop Univ Paris Nord Val Seine, AP HP, Dept Epidemiol Biostat & Rech Clin, Paris, France

[6] Krankenhaus Dueren, Dept Anesthesiol & Intens Care Med, Duren, Germany

[7] Univ Fed Minas Gerais, Hosp Clin, Dept Intens Care, Belo Horizonte, MG, Brazil

[8] Hop Raymond Poincare, AP HP, Crit Care Dept, Garches, France

[9] Jena Univ Hosp, Dept Anesthesiol & Intens Care Med, Jena, Germany

[10] Univ Hosp Liege, Dept Gen Intens Care, Domaine Univ Liege, Liege, Belgium

[11] Univ Groningen, Univ Med Ctr, Groningen, Netherlands

[12] Univ Med Ctr Utrecht, Utrecht, Netherlands

[13] Hosp Israelita Albert Einstein, Crit Care Unit, Lab Crit Care Res, Sao Paulo, Brazil

[14] Univ Fed Minas Gerais, Sch Med, Dept Internal Med, Belo Horizonte, MG, Brazil

[15] Monash Hlth, Crit Care & Perioperat Med, Melbourne, Vic, Australia

[16] Monash Univ, Fac Med Nursing & Hlth Sci, Sch Clin Sci, Melbourne, Vic, Australia

[17] Elisabeth Tweesteden Hosp, Tilburg, Netherlands

[18] Med Spectrum Twente, Enschede, Netherlands

[19] Vrije Univ Amsterdam, Med Ctr, Amsterdam, Netherlands

来源：

CRITICAL CARE | 2018年 / 22卷

关键词：

` Sepsis; Procalcitonin; Antibiotic stewardship; Meta-analysis; C-REACTIVE PROTEIN; SEPTIC SHOCK; ANTIMICROBIAL THERAPY; EMPIRICAL THERAPY; DE-ESCALATION; MANAGEMENT; INITIATION; MORTALITY; RISK; PNEUMONIA;

D O I：

10.1186/s13054-018-2125-7

中图分类号：

R4 [临床医学];

学科分类号：

1002 ; 100602 ;

摘要：

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.

引用

页数：11

共 45 条

[1] Effectiveness and safety of procalcitonin evaluation for reducing mortality in adults with sepsis, severe sepsis or septic shock [J].

Andriolo, Brenda N. G. ;

Andriolo, Regis B. ;

Salomao, Reinaldo ;

Atallah, Alvaro N. .

COCHRANE DATABASE OF SYSTEMATIC REVIEWS, 2017, (01)

[2] Procalcitonin levels to guide antibiotic therapy in adults with non-microbiologically proven apparent severe sepsis: a randomised controlled trial [J].

Annane, Djillali ;

Maxime, Virginie ;

Faller, Jean Pierre ;

Mezher, Chaouki ;

Clec'h, Christophe ;

Martel, Patricia ;

Gonzales, Helene ;

Feissel, Marc ;

Cohen, Yves ;

Capellier, Gilles ;

Gharbi, Miloud ;

Nardi, Olivier .

BMJ OPEN, 2013, 3 (02)

[3] Effect of Sodium Selenite Administration and Procalcitonin-Guided Therapy on Mortality in Patients With Severe Sepsis or Septic Shock A Randomized Clinical Trial [J].

Bloos, Frank ;

Trips, Evelyn ;

Nierhaus, Axel ;

Briegel, Josef ;

Heyland, Daren K. ;

Jaschinski, Ulrich ;

Moerer, Onnen ;

Weyland, Andreas ;

Marx, Gernot ;

Gruendling, Matthias ;

Kluge, Stefan ;

Kaufmann, Ines ;

Ott, Klaus ;

Quintel, Michael ;

Jelschen, Florian ;

Meybohm, Patrick ;

Rademacher, Sibylle ;

Meier-Hellmann, Andreas ;

Utzolino, Stefan ;

Kaisers, Udo X. ;

Putensen, Christian ;

Elke, Gunnar ;

Ragaller, Maximilian ;

Gerlach, Herwig ;

Ludewig, Katrin ;

Kiehntopf, Michael ;

Bogatsch, Holger ;

Engel, Christoph ;

Brunkhorst, Frank M. ;

Loeffler, Markus ;

Reinhart, Konrad .

JAMA INTERNAL MEDICINE, 2016, 176 (09) :1266-1276

[4] Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial [J].

Bouadma, Lila ;

Luyt, Charles-Edouard ;

Tubach, Florence ;

Cracco, Christophe ;

Alvarez, Antonio ;

Schwebel, Carole ;

Schortgen, Frederique ;

Lasocki, Sigismond ;

Veber, Benoit ;

Dehoux, Monique ;

Bernard, Maguy ;

Pasquet, Blandine ;

Regnier, Bernard ;

Brun-Buisson, Christian ;

Chastre, Jean ;

Wolff, Michel .

LANCET, 2010, 375 (9713) :463-474

[5] Adverse Drug Events Among Hospitalized Medicare Patients: Epidemiology and National Estimates from a New Approach to Surveillance [J].

Classen, David C. ;

Jaser, Lisa ;

Budnitz, Daniel S. .

JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY, 2010, 36 (01) :12-+

[6] Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial [J].

de Jong, Evelien ;

van Oers, Jos A. ;

Beishuizen, Albertus ;

Vos, Piet ;

Vermeijden, Wytze J. ;

Haas, Lenneke E. ;

Loef, Bert G. ;

Dormans, Tom ;

van Melsen, Gertrude C. ;

Kluiters, Yvette C. ;

Kemperman, Hans ;

van den Elsen, Maarten J. ;

Schouten, Jeroen A. ;

Streefkerk, Joern O. ;

Krabbe, Hans G. ;

Kieft, Hans ;

Kluge, Georg H. ;

van Dam, Veerle C. ;

van Pelt, Joost ;

Bormans, Laura ;

Otten, Martine Bokelman ;

Reidinga, Auke C. ;

Endeman, Henrik ;

Twisk, Jos W. ;

van de Garde, Ewoudt M. W. ;

de Smet, Anne Marie G. A. ;

Kesecioglu, Jozef ;

Girbes, Armand R. ;

Nijsten, Maarten W. ;

de lange, Dylan W. .

LANCET INFECTIOUS DISEASES, 2016, 16 (07) :819-827

[7] Clinical and economic impact of procalcitonin to shorten antimicrobial therapy in septic patients with proven bacterial infection in an intensive care setting [J].

Deliberato, Rodrigo Octavio ;

Marra, Alexandre R. ;

Sanches, Paula Rodrigues ;

Martino, Marines Dalla Valle ;

dos Santos Ferreira, Carlos Eduardo ;

Pasternak, Jacyr ;

Paes, Angela Tavares ;

Pinto, Lilian Moreira ;

Pavao dos Santos, Oscar Fernando ;

Edmond, Michael B. .

DIAGNOSTIC MICROBIOLOGY AND INFECTIOUS DISEASE, 2013, 76 (03) :266-271

[8]

DELLINGER RP, 2013, INTENS CARE MED, V39, P165, DOI DOI 10.1007/s00134-012-2769-8

[9] De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock [J].

Garnacho-Montero, J. ;

Gutierrez-Pizarraya, A. ;

Escoresca-Ortega, A. ;

Corcia-Palomo, Y. ;

Fernandez-Delgado, Esperanza ;

Herrera-Melero, I. ;

Ortiz-Leyba, C. ;

Marquez-Vacaro, J. A. .

INTENSIVE CARE MEDICINE, 2014, 40 (01) :32-40

[10] GRADE:: an emerging consensus on rating quality of evidence and strength of recommendations [J].

Guyatt, Gordon H. ;

Oxman, Andrew D. ;

Vist, Gunn E. ;

Kunz, Regina ;

Falck-Ytter, Yngve ;

Alonso-Coello, Pablo ;

Schuenemann, Holger J. .

BRITISH MEDICAL JOURNAL, 2008, 336 (7650) :924-926

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