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Ann Emerg Med. 2019 Apr 11. pii: S0196-0644(19)30147-7. doi: 10.1016/j.annemergmed.2019.02.025. [Epub ahead of print]

Guideline-Based Clinical Assessment Versus Procalcitonin-Guided Antibiotic Use in Pneumonia: A Pragmatic Randomized Trial.

Author information

1
Department of Emergency Medicine, Centre Hospitalier Universitaire, Nantes University Hospital, Nantes, France. Electronic address: emmanuel.montassier@chu-nantes.fr.
2
Department of Emergency Medicine, Centre Hospitalier Universitaire, Nantes University Hospital, Nantes, France.
3
Department of Emergency Medicine, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France.
4
Department of Emergency Medicine, Centre Hospitalier Agen Agen, France.
5
University Grenoble Alps, Emergency Department and Mobile Intensive Care Unit, Centre Hospitalier UniversitaireGrenoble Alps, Grenoble, France.
6
SPHERE U1246, Inserm, Université de Nantes-Université de Tours, Nantes, France.
7
Department of Emergency Medicine, Centre Hospitalier la Roche sur Yon, la Roche sur Yon, France.
8
Service de maladies infectieuses, Centre Hospitalier Universitaire Tours, Tours, France.
9
Department of Emergency Medicine, Assistance Publique Hopitaux de Paris, Hôpital Avicenne, Bobigny, France.
10
Department of Emergency Medicine, Centre Hospitalier Universitaire Angers, Institut Mitovasc, Université d'Angers, Angers, France.
11
Department of Emergency Medicine, Centre Hospitalier Universitaire Rennes, Rennes, France.
12
Department of Emergency Medicine, Centre Hospitalier Universitaire Strasbourg, Strasbourg, France.
13
Department of Emergency Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France.
14
Department of Emergency Medicine, Assistance Publique Hôpitaux de Paris, Hôpital Hôtel Dieu, Paris, France.
15
Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-University of California, Los Angeles Medical Center, Sylmar, California; David Geffen School of Medicine at University of California, Los Angeles. Electronic address: kelsey.miller@childrens.harvard.edu.

Abstract

STUDY OBJECTIVE:

Efforts to reduce unnecessary and unnecessarily long antibiotic treatment for community-acquired pneumonia have been attempted through use of procalcitonin and through guidelines based on serial clinical assessment. Our aim is to compare guideline-based clinical assessment- and procalcitonin algorithm-guided antibiotic use among patients with community-acquired pneumonia.

METHODS:

We performed a pragmatic, randomized, multicenter trial from November 2012 to April 2015 at 12 French hospitals. We included emergency department (ED) patients older than 18 years with community-acquired pneumonia. Patients were randomly assigned to either the procalcitonin-guided or clinical assessment group. In accordance with past studies, we hypothesized that serial clinical assessment would be superior to procalcitonin-guided care. The primary outcome was antibiotic duration, and secondary outcomes included rates of antibiotic duration less than or equal to 5 days, and clinical success and combined serious adverse outcomes at 30 days in the intention-to-treat population.

RESULTS:

Of 370 eligible patients, 285 (77%) were randomly assigned to either clinical assessment- (n=143) or procalcitonin-guided care (n=142). Median age was 67 years (range 18 to 93 years) and 40% of patients were deemed to have Pneumonia Severity Index class IV or V. Procalcitonin algorithm adherence was 76%. Antibiotic duration was not significantly different between clinical assessment- and procalcitonin-guided groups (median 9 versus 10 days, respectively). Clinical success rate was 92% in each group and serious adverse outcome rates were similar (15% versus 20%, respectively).

CONCLUSION:

Guideline-based serial clinical assessment did not reduce antibiotic exposure compared with procalcitonin-guided care among ED patients with community-acquired pneumonia. The strategies were similar in terms of duration of antibiotic use and clinical outcomes.

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