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Crit Care. 2018 Jan 27;22(1):17. doi: 10.1186/s13054-018-1948-6.

Do we need new trials of procalcitonin-guided antibiotic therapy?

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Rede Institucional de Pesquisa e Inovação em Medicina Intensiva, Complexo Hospitalar Santa Casa de Misericordia de Porto Alegre, Porto Alegre, Brazil.
Critical Care Department and Infection Control Committee, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil.
Instituto D'OR de pesquisa e ensino, Rio de Janeiro, Brazil.
Programa de pós-graduação de Clinica Medica Universidade Federal do Rio de Janeiro-UFRJ, Rio de Janeiro, Brazil.
Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.
NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisboa, Portugal.


Using biomarkers as a guide to tailor the duration of antibiotic treatment in respiratory infections is an attractive hypothesis assessed in several studies. Recent work aiming to summarize the evidence assessed the effect of a procalcitonin (PCT)-guided antibiotic treatment on outcomes in acute lower respiratory tract infections (LRTI), suggesting that significant reductions in antibiotic duration occur when using a PCT-guided algorithm. However, controversial evidence also suggested PCT-guided algorithms were associated with increased antibiotic duration and increased incidence of Clostridium difficile, without any impact on mortality, in real-world settings. So, although using PCT-guided antibiotic stewardship is promising, after more than a decade of randomized controlled trials on this topic the evidence in its favor is still less than compelling due to limitations in trial design, not taking into consideration fundamental aspects of PCT biology, and the absence of evidence-based antimicrobial duration in intervention and control groups. In this commentary we highlight some questions and limitations of primary PCT study data that might impact interpretation and clinical use of PCT at the bedside.

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