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Effect of procalcitonin-based guidelines vs standard ：前降钙素为基础的准则与标准的影响
Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 302(10):1059-66. (Sept 2009) Ria Dancel, MD 11/13/2009 Question: In adults with lower respiratory tract infection (LRTI), is antibiotic treatment based on a procalcitonin driven algorithm inferior to treatment based on current guidelines, in terms of adverse events? Rationale Antibiotic overuse – we all know the pitfalls: resistance, cost, adverse events, C. Diff 75% of patients with LRTI are prescribed antibiotics despite predominantly viral etiology Procalcitonin (PCT) is the precursor of calcitonin. Low or undetectable in healthy subjects Increases in proportion to severity of bacterial disease (infection, septicemia, meningitis) Falls quickly in response to appropriate antibiotic therapy Most importantly, PCT remains low in viral illness, making it a unique acute phase reactant that can potentially distinguish bacterial from viral infections Prior studies have suggested that algorithms using PCT cutoffs have decreased antibiotic use but these studies were small and insufficiently powered to show whether they caused more complications Study Design Investigator initiated, multicenter, noninferiority RCT 6 tertiary care centers in Switzerland Duration from 10/2006-3/2008 Power: Based on previous intervention trials, authors assumed overall adverse outcome risk of at most 20% Planning committee agreed that cut-off for inferiority would be risk greater than 27.5% Minimum sample size calculated to be 1002 patients to achieve 90% power Randomized concealed via centralized website Inclusion criteria 18 years or older, from community or nursing home LRTI 28 days in duration 1 respiratory symptom (cough, sputum production, dyspnea, tachypnea, pleuritic pain) PLUS 1 auscultory finding (rales, crepitation) OR 1 sign of infection (fever 38, shivering, WBC 10K or 4K) Definitions CAP = LRTI with new i
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