Eva Heilmann, Claudia Gregoriano, Yannick Wirz, Charles-Edouard Luyt, Michel Wolff, Jean Chastre, Florence Tubach, Mirjam Christ-Crain, Lila Bouadma, Djillali Annane, Pierre Damas, Kristina B. Kristoffersen, Carolina F. Oliveira, Daiana Stolz, Michael Tamm, Evelien de Jong, Konrad Reinhart, Yahya Shehabi, Alessia Verduri, Vandack Nobre, Maarten Nijsten, Dylan W. deLange, Jos A.H. van Oers, Albertus Beishuizen, Armand R.J. Girbes, Beat Mueller, Philipp Schuetz
September 28, 2020
Objectives Patients with impaired kidney function have a significantly slower decrease of procalcitonin (PCT) levels during infection. Our aim was to study PCT-guided antibiotic stewardship and clinical outcomes in patients with impairments of kidney function as assessed by creatinine levels measured upon hospital admission. Methods We pooled and analyzed individual data from 15 randomized controlled trials who were randomly assigned to receive antibiotic therapy based on a PCT-algorithms or based on standard of care. We stratified patients on the initial glomerular filtration rate (GFR, ml/min/1.73 m 2 ) in three groups (GFR >90 [chronic kidney disease; CKD 1], GFR 15–89 [CKD 2–4] and GFR<15 [CKD 5]). The main efficacy and safety endpoints were duration of antibiotic treatment and 30-day mortality. Results Mean duration of antibiotic treatment was significantly shorter in PCT-guided (n=2,492) compared to control patients (n=2,510) (9.5–7.6 days; adjusted difference in days −2.01 [95% CI, −2.45 to −1.58]). CKD 5 patients had overall longer treatment durations, but a 2.5-day reduction in treatment duration was still found in patients receiving in PCT-guided care (11.3 vs. 8.6 days [95% CI −3.59 to −1.40]). There were 397 deaths in 2,492 PCT-group patients (15.9%) compared to 460 deaths in 2,510 control patients (18.3%) (adjusted odds ratio, 0.88 [95% CI 0.78 to 0.98)]. Effects of PCT-guidance on antibiotic treatment duration and mortality were similar in subgroups stratified by infection type and clinical setting (p interaction >0.05). Conclusions This individual patient data meta-analysis confirms that the use of PCT in patients with impaired kidney function, as assessed by admission creatinine levels, is associated with shorter antibiotic courses and lower mortality rates.