Biomarkers may help guide antibiotic stewardship in community acquired pneumonia

1. Using either procalcitonin or c-reactive protein as a biomarker to guide antibiotic treatment in patients with community-acquired pneumonia reduces the length of treatment course with no effect to time to reach stability or new antibiotic prescriptions

Evidence Rating Level: 1 (Excellent) 

20-50% of the 3.3 million people who develop community-acquired pneumonia (CAP) need to be hospitalized every year. Treatment of CAP is recommended to be a 5-21 day course of antibiotics yet in practice, patients are treated for longer than recommended. Biomarkers have been proposed to be an objective measure of when to start and stop antibiotic treatment in patients with CAP. These biomarkers include procalcitonin (PCT) and C-reactive protein (CRP). PCT is used as a marker of bacterial infection and CRP is a marker of inflammation. This randomized controlled trial aimed to look at the effects of a treatment algorithm based on PCR or CRP on the duration of antibiotic treatment in patients hospitalized with CAP. The control group’s treatment endpoint was determined by the attending physician. In either of the experimental groups, CRP or PCT respectively were determined on day 1 of admission and day 4. If on day 4, the level was below the threshold values (100 mg/L and a reduction to below 50% of the initial value for CRP and below 0.25 μg/L or a reduction to below 10% of the initial value for PCT), antibiotics were discontinued. If not, daily CRP and PCT were taken until the threshold was reached or until day 7 at the latest. The primary outcome was the total number of days on antibiotic treatment (IV and oral) until day 30. Secondary outcomes were new prescriptions, hospital stay length, clinical stability time, and all-cause mortality. In both experimental groups, the length of antibiotic course was reduced. The control group had an average treatment course of 7 days. There was a 30% reduction to a median of 4 days in the CRP group (pp<0.001) and by 22% to a median of 5.5 days in the PCT group (p<0.001). No significant changes were seen in time to reach clinical stability or new antibiotic prescriptions. Therefore, using either the CRP or PCT biomarkers reduced the duration of antibiotics used in patients hospitalized with CAP while having no change in the time needed to reach clinical stability or receive a new antibiotic prescription. The key limitation of this study is that it was underpowered to exclude harm due to the reduced duration of antibiotic treatment.  

Click to read the study in PLOSONE

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