Source: Huang DT et al. Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. N Engl J Med. 2018 May 20.
Sepsis (well more correctly severe sepsis/shock) is as dangerous as fake news but so is ordering cr(a)p that wont help you in the management of your patients. The current darling of the useless tests is procalcitonin. While I agree it is the better than any test we’ve had before for infection, is it any better than physician judgement (not clouded by false worries of lawsuits, that is)? My first RAPID REVIEW is on just this topic.
In May 2018, Huang et al. (shout out to my friend Frank Lovecchio!) published an article in NEJM and looked at the effect of procalcitonin-guided use of antibiotics in the treatment for suspected lower respiratory tract infections (LRTI). As we all know these should mostly be treated as viral syndromes and with supportive care. Unfortunately, this is rarely the case as most patient get the terrible trifecta of prednisone, azithromycin, and albuterol. So, can we spare the most commonly prescribed anti-viral (azithromycin that is)? Can procalcitonin improve antibiotic stewardship? Let’s find out…
METHODS: This was a multi-center (14 to be exact) randomized controlled trial of adults >18 yo in whom the treating clinician had given an initial diagnosis of acute lower respiratory tract infection but had not yet decided to give antibiotics and about whom there was uncertainty regarding the need for antibiotics. They categorized the initial diagnosis of lower respiratory tract infection into one of the following final diagnoses: acute exacerbation of chronic obstructive pulmonary disease (COPD), asthma exacerbation, acute bronchitis, community-acquired pneumonia (CAP), and other. Here is the key. The intervention group was given training (although I thought this was called medical school…) in appropriate use of antibiotics for LRTI’s; the other group used procalcitonin. The primary outcome was total antibiotic exposure, defined as the total number of antibiotic days within 30. The primary safety outcome was a composite of adverse outcomes that could be attributable to withholding antibiotics in lower respiratory tract infection, within 30 days after enrollment.
RESULTS: There was no significant difference in antibiotic exposure during the first 30 days between the procalcitonin group and the usual-care group. This was true for both the intention-to-treat and per-protocol analyses. In the study, 1345 (81.2%) patients completed the 30-day follow-up. The two groups were similar in baseline characteristics. Final diagnoses included asthma (646 pts, 39.3%), COPD (524 pts, 31.9%), bronchitis (398 pts, 24.2%), and CAP (328 pts, 19.9%). In the secondary outcomes there was no differences in overall adverse events looked at: death, endotracheal intubation, vasopressors, renal failure, lung abscess/empyema, or hospital readmission. ICU admissions were equal in both the procalcitonin group and in the usual care group (4.8%). Subsequent ED visits were 19.5% in both groups.
TAKE AWAY: So obviously we now know that…If we turn our brains off we can just let the procalcitonin do the work for us? Ummm…. Let’s hope that’s not the take away. Its apparent that using good judgement is just something we physicians are going to have to keep doing. Hopefully, studies like this are “infectious” so that we can continue to realize that we physicians are an important step in the process. We can’t just “click a bunch of buttons” and let the EHR do our job for us because it won’t result in the same care. Health care as it is, is expensive enough. Plus, a human will always be better than machine in taking care of other humans. I want to personally thank the authors for doing this study!