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Biomarker-guided antibiotic therapy in adult critically ill patients: a critical review.

Póvoa P, Salluh JI - Ann Intensive Care (2012)

Bottom Line: C-reactive protein variations overtime appears to have a good performance for the diagnosis of infection.Procalcitonin shows a better correlation with clinical severity.Future studies should take into account the issues identified in the present review.

View Article: PubMed Central - HTML - PubMed

Affiliation: Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, Lisbon 1449-005, Portugal. povoap@netcabo.pt.

ABSTRACT
Biomarkers of infection, namely C-reactive protein and procalcitonin (PCT), are potentially useful in the diagnosis of infection as well as in the assessment of its response to antibiotic therapy. C-reactive protein variations overtime appears to have a good performance for the diagnosis of infection. Procalcitonin shows a better correlation with clinical severity. In addition, to overcome the worldwide problem of antibiotic overuse as well as misuse, biomarker guidance of antibiotic stewardship represents a promising new approach. In several randomized, controlled trials, including adult critically ill patients, PCT guidance was repeatedly associated with a decrease in the duration of antibiotic therapy. However, these trials present several limitations, namely high rate of patients' exclusion, high rate of algorithm overruling, long duration of antibiotic therapy in the control group, disregard the effect of renal failure on PCT level, and above all a possible higher mortality and higher late organ failure in the PCT arm. In addition, some infections (e.g., endocarditis) as well as frequent nosocomial bacteria (e.g., Pseudomonas aeruginosa) are not suitable to be assessed by PCT algorithms. Therefore, the true value of PCT-guided algorithm of antibiotic stewardship in assisting the clinical decision-making process at the bedside remains uncertain. Future studies should take into account the issues identified in the present review.

No MeSH data available.


Related in: MedlinePlus

Procalcitonin algorithm for stewardship of antibiotic therapy; adapted from [[10]].
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Figure 1: Procalcitonin algorithm for stewardship of antibiotic therapy; adapted from [[10]].

Mentions: The proposed algorithms on antibiotic stewardship are based on different PCT cutoff ranges. These cutoffs were derived from several well-conducted, prospective, observational studies and were validated in different RCT [40]. The PCT algorithm for primary care and emergency departments can be summarized as follows: antibiotics were more or less discouraged (<0.1 ng/mL or 0.1–0.25 ng/mL) or encouraged (>0.25–0.5 ng/mL or >0.5 ng/mL) [10]. According to these PCT cutoff ranges, bacterial etiology was considered very unlikely, unlikely, likely, and very likely, respectively [10]. To prevent not treating an infection, some overruling criteria were included in the algorithm (Figure 1) [10].


Biomarker-guided antibiotic therapy in adult critically ill patients: a critical review.

Póvoa P, Salluh JI - Ann Intensive Care (2012)

Procalcitonin algorithm for stewardship of antibiotic therapy; adapted from [[10]].
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3475044&req=5

Figure 1: Procalcitonin algorithm for stewardship of antibiotic therapy; adapted from [[10]].
Mentions: The proposed algorithms on antibiotic stewardship are based on different PCT cutoff ranges. These cutoffs were derived from several well-conducted, prospective, observational studies and were validated in different RCT [40]. The PCT algorithm for primary care and emergency departments can be summarized as follows: antibiotics were more or less discouraged (<0.1 ng/mL or 0.1–0.25 ng/mL) or encouraged (>0.25–0.5 ng/mL or >0.5 ng/mL) [10]. According to these PCT cutoff ranges, bacterial etiology was considered very unlikely, unlikely, likely, and very likely, respectively [10]. To prevent not treating an infection, some overruling criteria were included in the algorithm (Figure 1) [10].

Bottom Line: C-reactive protein variations overtime appears to have a good performance for the diagnosis of infection.Procalcitonin shows a better correlation with clinical severity.Future studies should take into account the issues identified in the present review.

View Article: PubMed Central - HTML - PubMed

Affiliation: Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, Lisbon 1449-005, Portugal. povoap@netcabo.pt.

ABSTRACT
Biomarkers of infection, namely C-reactive protein and procalcitonin (PCT), are potentially useful in the diagnosis of infection as well as in the assessment of its response to antibiotic therapy. C-reactive protein variations overtime appears to have a good performance for the diagnosis of infection. Procalcitonin shows a better correlation with clinical severity. In addition, to overcome the worldwide problem of antibiotic overuse as well as misuse, biomarker guidance of antibiotic stewardship represents a promising new approach. In several randomized, controlled trials, including adult critically ill patients, PCT guidance was repeatedly associated with a decrease in the duration of antibiotic therapy. However, these trials present several limitations, namely high rate of patients' exclusion, high rate of algorithm overruling, long duration of antibiotic therapy in the control group, disregard the effect of renal failure on PCT level, and above all a possible higher mortality and higher late organ failure in the PCT arm. In addition, some infections (e.g., endocarditis) as well as frequent nosocomial bacteria (e.g., Pseudomonas aeruginosa) are not suitable to be assessed by PCT algorithms. Therefore, the true value of PCT-guided algorithm of antibiotic stewardship in assisting the clinical decision-making process at the bedside remains uncertain. Future studies should take into account the issues identified in the present review.

No MeSH data available.


Related in: MedlinePlus