3児の親さん薬剤師のブログ

とある薬剤師です。感染症治療を考える素材をちょこっと提供。https://note.mu/twin1980。

Procalcitonin-guided antibiotic treatment in patients with positive blood cultures: A patient-level meta-analysis of randomized trials

CIDに報告された、菌血症に対するPCT-guided antibioticメタアナ。

 

academic.oup.com

 

感想

 

菌血症に対して、使用日数を2.86日短縮させたことは素晴らしいです。

現在のCRPのように、盲目的に使用しないことが重要ですが。

 

死亡率は同等。

抗菌薬治療期間は減少。

特に下記の感染症に対する抗菌薬治療期間が減少。

Streptococcus pneumoniae respiratory infection

E. coli urogenital infections

 

 

 

Abstract

Background

Whether procalcitonin (PCT)-guided antibiotic management in patients with positive blood cultures is safe remains understudied. We performed a patient level meta-analysis to investigate effects of PCT-guided antibiotic management in patients with bacteremia overall and stratified based on type of pathogen.

Methods

We extracted and analysed individual data of 523 patients with positive blood cultures included in 13 trials (7 studies evaluating patients with acute respiratory illnesses, 6 studies patients with sepsis), in which patients were randomly assigned to receive antibiotics based on PCT levels (PCT group) or a control group. The main efficacy endpoint was duration of antibiotic treatment. The main safety endpoint was mortality within 30 days.

Results

Mean duration of antibiotic therapy for 253 patients who received PCT guided treatment was significantly shorter compared to 270 control patients (-2.86 days (95%CI -4.88 to -0.84, p=0.006). Mortality was similar in both arms (16.6% vs 20.0%, p=0.263). In subgroup analyses by type of pathogen, we noted a trend of shorter mean antibiotic durations in the PCT arm for patients infected with gram positive organisms or Escherichia coli and significantly shorter treatment for subjects with pneumococcal bacteremia (-4.52 days [95%CI -7.40 to -1.64, p=0.002). In analysis by site of infection, antibiotics exposure was shortened in PCT group subjects with Streptococcus pneumoniae respiratory infection and those with Escherichia coli urogenital infections.

Conclusion

This meta-analysis of patients with bacteremia receiving PCT-guided antibiotic management demonstrates lower antibiotic exposure without an apparent increase in mortality. Few differences were demonstrated in subgroup analysis stratified by type or site of infection but notable for decreased exposure in patients with pneumococcal pneumonia and E Coli urogenital infections.

  

f:id:akinohanayuki:20181026053300p:plain

 

References

 

  1. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Archives of internal medicine 2003; 163(8): 972-8.

  2. Huttner A, Harbarth S, Carlet J, et al. Antimicrobial resistance: a global view from the 2013 World Healthcare-Associated Infections Forum. Antimicrob Resist Infect Control 2013; 2: 31.

  3. NICE antimicrobial stewardship: right drug, dose, and time? Lancet 2015; 386(9995): 717.

  4. Sager R, Kutz A, Mueller B, Schuetz P. Procalcitonin-guided diagnosis and antibiotic stewardship

    revisited. BMC medicine 2017; 15(1): 15.

  5. Mitsuma SF, Mansour MK, Dekker JP, et al. Promising new assays and technologies for the diagnosis and management of infectious diseases. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2013; 56(7): 996-1002.

  6. FDA press release. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm543160.htm

2017.

  1. Schuetz P, Birkhahn R, Sherwin R, et al. Serial Procalcitonin Predicts Mortality in Severe Sepsis Patients: Results From the Multicenter Procalcitonin MOnitoring SEpsis (MOSES) Study. Critical care medicine 2017; 45(5): 781-9.

  2. Schuetz P, Wirz Y, Sager R, et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. The Lancet infectious diseases2018; 18(1): 95-107.

  3. Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane database of systematic reviews 2017; 10: CD007498.

  4. Woodhead M, Blasi F, Ewig S, et al. Guidelines for the management of adult lower respiratory tract infections--full version. Clin Microbiol Infect 2011; 17 Suppl 6: E1-59.

  5. Schuetz P, Briel M, Christ-Crain M, et al. Procalcitonin to initiate or withhold antibiotics in acute respiratory tract infections (Protocol). Cochrane database of systematic reviews 2008; (Issue 4. Art. No.: CD007498).

  6. Schuetz P, Muller B, Christ-Crain M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane database of systematic reviews 2012; 9(9): CD007498.

  1. Stewart LA, Clarke M, Rovers M, et al. Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data: the PRISMA-IPD Statement. JAMA : the journal of the American Medical Association 2015; 313(16): 1657-65.

  2. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of clinical epidemiology 2009; 62(10): e1-34.

  3. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Bmj 2008; 336(7650): 924-6.

  4. Thompson SG, Turner RM, Warn DE. Multilevel models for meta-analysis, and their application to absolute risk differences. Statistical methods in medical research 2001; 10(6): 375-92.

  5. Turner RM, Omar RZ, Yang M, Goldstein H, Thompson SG. A multilevel model framework for meta-analysis of clinical trials with binary outcomes. Statistics in medicine 2000; 19(24): 3417- 32.

  6. Schuetz P, Bolliger R, Merker M, et al. Procalcitonin-guided antibiotic therapy algorithms for different types of acute respiratory infections based on previous trials. Expert review of anti- infective therapy 2018; 16(7): 555-64.

  7. Schuetz P, Briel M, Christ-Crain M, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America2012; 55(5): 651-62.

  8. Muller F, Christ-Crain M, Bregenzer T, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest 2010; 138(1): 121-9.

  9. Drozdov D, Schwarz S, Kutz A, et al. Procalcitonin and pyuria-based algorithm reduces antibiotic use in urinary tract infections: a randomized controlled trial. BMC medicine 2015; 13: 104.

  10. Sandberg T, Skoog G, Hermansson AB, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non- inferiority trial. Lancet 2012; 380(9840): 484-90.

  11. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49(1): 1-45.

  12. Nelson AN, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al-Hasan MN. Optimal duration of antimicrobial therapy for uncomplicated Gram-negative bloodstream infections. Infection 2017; 45(5): 613-20.

  1. Chotiprasitsakul D, Han JH, Cosgrove SE, et al. Comparing the Outcomes of Adults With Enterobacteriaceae Bacteremia Receiving Short-Course Versus Prolonged-Course Antibiotic Therapy in a Multicenter, Propensity Score-Matched Cohort. Clin Infect Dis 2018; 66(2): 172-7.

  2. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med 2015; 372(21): 1996-2005.

  3. Huang DT, Yealy DM, Filbin MR, et al. Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. The New England journal of medicine 2018; 379(3): 236-49.

 

 

 

合わせて読みたい

 

Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30592-3/fulltext

 

 

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シュロスバーグの臨床感染症学

シュロスバーグの臨床感染症学