High adherence to procalcitonin-guided antibiotic prescribing guideline may reduce antibiotic use in hospitals

By Dr. Sanchari Sinha Dutta, Ph.D.Jan 23 2023Reviewed by Aimee Molineux

A study published in the journal BMC Infectious Diseases claims that high adherence to procalcitonin-guided antibiotic prescribing guidelines is necessary to reduce antibiotic use in patients with suspected lower respiratory tract infections.

Study: Impact of adherence to procalcitonin antibiotic prescribing guideline recommendations for low procalcitonin levels on antibiotic use. Image Credit: solarseven / Shutterstock

Background

Procalcitonin, which is the precursor of the hormone calcitonin, is regarded as a circulating biomarker specific for bacterial infection. The blood level of this peptide increases during bacterial infection but not during viral infection. Procalcitonin blood test is used in various clinical settings to support the diagnosis of bacterial infection or sepsis.

Procalcitonin-guided antibiotic prescribing guidelines have been introduced in clinical settings to reduce antibiotic use and prevent antibiotic resistance. This is particularly relevant for acute respiratory tract infections wherein antibiotics are frequently prescribed despite most infections being caused by viruses and not by bacteria.

The Procalcitonin Antibiotic Consensus Trial (ProACT) is a multicenter randomized trial to determine the effectiveness of procalcitonin-guided antibiotic prescribing guidelines in reducing antibiotic use among US patients with suspected lower respiratory tract infection.

The trial failed to find any significant reduction in antibiotic use in clinical settings. Specifically, the trial findings indicated that hospital clinicians did not reduce the use of antibiotics for respiratory tract infections, despite having access to procalcitonin-guided antibiotic prescribing guidelines and procalcitonin blood test results of patients. This could be due to the reluctance of clinicians to follow the guidelines. In addition, the trial found a low guideline adherence rate of 64.8%.    

In the current study, scientists have conducted a retrospective analysis of the ProACT data, which included 1,656 patients with suspected lower respiratory tract infections from 14 US hospitals, to determine the threshold adherence rate of procalcitonin-guided antibiotic prescribing guidelines that is required to reduce antibiotic use. They have also explored opportunities to increase adherence rates.

Study design

The study aimed to determine the impact of guideline adherence rate on the number of antibiotic days by day 30 using an intention-to-treat approach and a null hypothesis (no difference between groups).

They simulated varying adherence (65% - 100%) to the guideline for low procalcitonin levels in the intervention arm patients. They determined the threshold adherence rate that might be useful in reducing antibiotic prescription by hospital clinicians. Moreover, they determined the threshold rate for continued guideline adherence after discharge.

Important observations

The study analysis indicated that a guideline adherence rate of 84% in hospital settings (emergency department and inpatient) for low procalcitonin levels in the intervention arm patients is required to reduce the number of antibiotic days by day 30 significantly. Complete guideline adherence in the hospital (100%) would have resulted in 0.9 fewer antibiotic days.

According to the study findings, antibiotic treatments were withdrawn initially in 469 patients with low procalcitonin levels. About 36% of them again received antibiotics after discharge. For continued guideline adherence after discharge, the threshold adherence rate was 76% to reduce antibiotic use. A complete guideline adherence after discharge (100%) would have resulted in 1.7 fewer antibiotic days.

The study also identified 218 patients who were prescribed antibiotics despite having low procalcitonin levels. About 7.8%, 62.4%, and 29.8% were categorized as low-, medium-, and high-risk of illness severity or bacterial infection.

Study significance

The study highlights that high adherence to procalcitonin-guided antibiotic prescribing guidelines in the hospital setting is necessary to reduce antibiotic use in the US.

As mentioned by the scientists in the journal, “Continued guideline adherence after discharge and withholding of antibiotics in low and medium risk patients with low procalcitonin may offer impactful potential opportunities for antibiotic reduction.”