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Association of kidney function with effectiveness of procalcitonin-guided antibiotic treatment: a patient-level meta-analysis from randomized controlled trials.

Medical University Department, Kantonsspital Aarau, Aarau, Switzerland. Service de Médecine Intensive Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France. Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France. Département d'Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France. Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Basel, Switzerland. Department of Critical Care, Hyperbaric Medicine and Home Respiratory Unit, Center for Neuromuscular Diseases, Raymond Poincaré Hospital (AP-HP), Garches, France. Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Liege, Belgium. Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark. Department of Internal Medicine, School of Medcine, Federal University of Minas Gerais, Belo Horizonte, Brazil. Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland. Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands. Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany. Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany. Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Australia. School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia. Department of Medical and Surgical Sciences,Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy. Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. University Medical Centre, University of Groningen, Groningen, The Netherlands. University Medical Center Utrecht, Utrecht, The Netherlands. Elisabeth Tweesteden Hospital, Tilburg, The Netherlands. Medisch Spectrum Twente, Enschede, The Netherlands. Faculty of Medicine, University of Basel, Basel, Switzerland.

Clinical chemistry and laboratory medicine. 2020;(2):441-453
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Abstract

OBJECTIVES Patients with impaired kidney function have a significantly slower decrease of procalcitonin (PCT) levels during infection. Our aim was to study PCT-guided antibiotic stewardship and clinical outcomes in patients with impairments of kidney function as assessed by creatinine levels measured upon hospital admission. METHODS We pooled and analyzed individual data from 15 randomized controlled trials who were randomly assigned to receive antibiotic therapy based on a PCT-algorithms or based on standard of care. We stratified patients on the initial glomerular filtration rate (GFR, ml/min/1.73 m2) in three groups (GFR >90 [chronic kidney disease; CKD 1], GFR 15-89 [CKD 2-4] and GFR<15 [CKD 5]). The main efficacy and safety endpoints were duration of antibiotic treatment and 30-day mortality. RESULTS Mean duration of antibiotic treatment was significantly shorter in PCT-guided (n=2,492) compared to control patients (n=2,510) (9.5-7.6 days; adjusted difference in days -2.01 [95% CI, -2.45 to -1.58]). CKD 5 patients had overall longer treatment durations, but a 2.5-day reduction in treatment duration was still found in patients receiving in PCT-guided care (11.3 vs. 8.6 days [95% CI -3.59 to -1.40]). There were 397 deaths in 2,492 PCT-group patients (15.9%) compared to 460 deaths in 2,510 control patients (18.3%) (adjusted odds ratio, 0.88 [95% CI 0.78 to 0.98)]. Effects of PCT-guidance on antibiotic treatment duration and mortality were similar in subgroups stratified by infection type and clinical setting (p interaction >0.05). CONCLUSIONS This individual patient data meta-analysis confirms that the use of PCT in patients with impaired kidney function, as assessed by admission creatinine levels, is associated with shorter antibiotic courses and lower mortality rates.

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Publication Type : Meta-Analysis

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