J Infect Chemother. 2017 Mar;23(3):142-147. doi: 10.1016/j.jiac.2016.11.006.

Impact of procalcitonin-guided therapy for hospitalized community-acquired pneumonia on reducing antibiotic consumption and costs in Japan.

Ito A1, Ishida T2, Tokumasu H3, Washio Y2, Yamazaki A2, Ito Y2, Tachibana H4.

1Department of Respiratory Medicine, Ohara Memorial Kurashiki Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan. Electronic address: ai12306@kchnet.or.jp.
2Department of Respiratory Medicine, Ohara Memorial Kurashiki Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan.
3Department of Clinical Research Institute, Ohara Memorial Kurashiki Healthcare Foundation, Kurashiki Central Hospital, Okayama, Japan.
4Department of Respiratory Medicine, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan.

 

Abstract

BACKGROUND AND OBJECTIVE:

This study aimed to investigate the usefulness of procalcitonin-guided therapy in hospitalized community-acquired pneumonia patients to reduce antibiotic duration and costs without worsening prognosis.

METHODS:

352 hospitalized community-acquired pneumonia patients in an observational cohort study in which procalcitonin was measured three times serially, on admission (Day 1) and 2-3 days (Day 3) and 6-8 days (Day 7) after admission, between October 2010 and February 2016 were reviewed retrospectively. Antibiotics could be stopped if Day 7 procalcitonin was <0.25 ng mL-1 or ≤10% of the higher value of procalcitonin on Day 1 or 3. Antibiotic duration and costs and recurrence and mortality rates were evaluated in mild to moderate or severe pneumonia by theoretical procalcitonin guidance for community-acquired pneumonia treatment.

RESULTS:

Using theoretical procalcitonin guidance, antibiotic duration could be reduced from 12.6 to 8.6 days (P < 0.001), while costs could be reduced from 45,833 to 38,952 yen (P = 0.005). Among the patients in whom theoretical procalcitonin guidance could be adopted, recurrence rates (5.6% vs. 8.1%, P = 0.15) and mortality rates (0% vs. 5.1%, P = 0.07) did not worsen between the group having the same antibiotic durations as with theoretical procalcitonin guidance in actual practice (N = 71) and the group having durations more than 2 days longer in actual practice than in theoretical procalcitonin guidance (N = 198). There was no significant difference in pneumonia severity using A-DROP, CURB-65, and PSI between two groups.

CONCLUSIONS:

Procalcitonin-guided therapy may be useful in hospitalized community-acquired pneumonia patients to reduce antibiotic duration and costs without worsening the prognosis.

Antibacterial agents; Community-acquired pneumonia; Cost benefit analysis; Procalcitonin; Prognosis

PMID: 28024740

 

Supplement:

Procalcitonin (PCT) is the precursor of calcitonin, which is a 116-amino acid peptide that is secreted by the C-cells of the thyroid. In healthy individuals, the serum PCT is very low at <0.1 ng/mL. Assicot et al. [1] were the first to report in 1993 that PCT increases in patients with bacterial infection. When bacterial infection occurs, PCT is released in a cytokine-like manner by parenchymal cells such in the liver, kidney, lungs, and adipocytes, but not by leukocytes [2].

For community-acquired pneumonia (CAP), some reports showed that the PCT levels on admission correlated with the severity and prognosis of pneumonia [3–5]. Moreover, serial PCT measurements were reported by some to be useful for predicting prognosis and initial treatment failure [6–8]. Christ-Crain et al. reported that compared with standard care, PCT guidance reduced the number of antibiotic prescriptions on admission (85% vs. 99%; P < 0.001) and the median duration antibiotic treatment (5 days vs. 12 days; P < 0.001) without worsening the mortality and recurrence rates [9]. In that study, initiation or continuation of antibiotics was 1) strongly discouraged if a PCT level of less than 0.1 μg/L; 2) discouraged if the PCT level was between 0.1 and 0.25 μg/L; 3) encouraged if the PCT level was between 0.25 and 0.5 μg/L; and 4) strongly encouraged if the PCT level was greater than 0.5 μg/L. Furthermore, PCT-guided therapy for CAP had been reported to reduce antibiotic costs [10].

Currently, in Japan, the use of PCT as biomarker in CAP management is not more popular than the use of white blood cell count or C-reactive protein. Moreover, there is no Randomised Controlled Trial (RCT) that has proven that PCT guidance in CAP reduced antibiotic duration and costs. Therefore, we conducted a study based on the hypothesis that theoretical PCT guidance could reduce the duration and cost of antibiotic treatment without worsening prognosis.

Based on previous reports, we defined theoretical PCT guidance as cessation of antibiotics for CAP if PCT on day 7 was <0.25 ng mL-1 or ≤10% of the higher PCT value between day 1 and day 3 (Figure 1). Using these criteria, our study showed that PCT guidance significantly reduced the antibiotic duration from 12.6 days to 8.6 days (P < 0.001) and cost from JPY 45,833 to JPY 38,952 (P = 0.005) without worsening the mortality rate (0% vs. 5.1%, P = 0.07) and recurrence rate (5.6% vs. 8.1%, P = 0.15) compared with the actual treatment. However, it is important to note that our study was a virtual research; therefore, an RCT on the effect of PCT guidance on antibiotic duration and cost in Japan is needed in the future.

 

 

Figure 1. Theoretical procalcitonin guidance of antibiotic therapy in CAP. The patients in whom PCT was measured for 3 consecutive days were included; these measurements were on admission (PCT day 1), within 48 to 72 hours after admission (PCT day 3), and within 120 to 168 hours after admission (PCT day 7). Theoretical PCT guidance was defined as cessation of antibiotics if PCT day 7 was <0.25 ng mL-1 or ≤10% of the higher value between PCT day 1 and PCT day 3. CAP, community-acquired pneumonia; PCT, procalcitonin

 

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