Ineffectiveness of procalcitonin-guided antibiotic therapy in severely critically ill patients: A meta-analysis

Abstract

Background: Optimizing antibiotic therapy has an important impact on the management of critically ill patients. Procalcitonin (PCT) is considered to be of possible use in the guidance of antibiotic stewardship; however, its efficacy remains controversial. Thus, a meta-analysis was performed to determine the efficacy of PCT-guided antibiotic therapy in critically ill patients.

Methods: The relevant literature was searched in PubMed, Embase, Web of Science, and the Cochrane Library covering the period from 2004 to August 2018. Randomized controlled trials (RCTs) were included if critically ill patients were treated with PCT-guided antibiotic therapy or standard care. The primary outcome was short-term mortality; secondary endpoints were the duration of antibiotic treatment, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

Results: Sixteen RCTs enrolling 6452 critically ill patients were included in this analysis. The pooled analysis demonstrated a comparable short-term mortality (rate ratio (RR) 0.90, 95% confidence interval (CI) 0.80-1.01; p= 0.07), ICU LOS (mean difference (MD) 0.38, 95% CI -0.05 to 0.81; p=0.09), and hospital LOS (MD 0.19, 95% CI -1.56 to 1.95; p= 0.83) for PCT-guided antibiotic therapy and standard antibiotic therapy, and an antibiotic duration shorter by 0.99 days (95% CI -1.85 to -0.13 days; p= 0.02) for PCT-guided antibiotic therapy. In the subgroup analysis, patients with an average Sequential Organ Failure Assessment (SOFA) score of <8 in the PCT-guided cessation of antibiotics group had a lower short-term mortality compared with the standard care group (RR 0.81, 95% CI 0.66-0.99; p= 0.04), while no difference was found in the subgroup with an average SOFA score of >8 (RR 0.85, 95% CI 0.66-1.11; p=0.23).

Conclusions: PCT-guided antibiotic therapy fails to decrease the mortality or LOS of critically ill patients with suspected or confirmed sepsis. PCT-guided cessation of antibiotic therapy could reduce the mortality in patients with an average SOFA score of <8, but not in those with an average SOFA score of >8.

Keywords: Antibiotic therapy; Critically ill; Meta-analysis; Procalcitonin; Sepsis; Systematic review.