• Philipp Schuetz, Rebekka Bolliger, Meret Merker, Mirjam Christ-Crain, Daiana Stolz, Michael Tamm, Charles E Luyt, Michel Wolff, Stefan Schroeder, Vandack Nobre, Konrad Reinhart, Angela Branche, Pierre Damas, Maarten Nijsten, Rodrigo O Deliberato, Alessia Verduri, Bianca Beghé, Bin Cao, Yahya Shehabi, JensenJens-Ulrik SJSr CHIP & PERSIMUNE, Department of Infectious Diseases , Rigshospitalet, University of Copenhagen , Copenhagen , Denmark.s Department of Internal Medicine, Respiratory Medicine Section , Herlev-Gentofte Hospital , Hellerup , Denmark., Albertus Beishuizen, Evelien de Jong, Matthias Briel, Tobias Welte, and Beat Mueller.
• a Faculty of Medicine , University of Basel , Basel , Switzerland.
• Expert Rev Anti Infect Ther. 2018 Jul 1; 16 (7): 555-564.

IntroductionAlthough evidence indicates that use of procalcitonin to guide antibiotic decisions for the treatment of acute respiratory infections (ARI) decreases antibiotic consumption and improves clinical outcomes, algorithms used within studies had differences in PCT cut-off points and frequency of testing. We therefore analyzed studies evaluating procalcitonin-guided antibiotic therapy and propose consensus algorithms for different respiratory infection types. Areas covered: We systematically searched randomized-controlled trials (search strategy updated on February 2018) on procalcitonin-guided antibiotic therapy of ARI in adults using a pre-specified Cochrane protocol and analyzed algorithms from 32 trials that included 10,285 patients treated in primary care settings, emergency departments (ED), and intensive care units (ICU). We derived consensus algorithms for use of procalcitonin by the type of ARI including community-acquired pneumonia, bronchitis, chronic obstructive pulmonary disease or asthma exacerbation, sepsis, and post-operative sepsis due to respiratory infection. Consensus algorithm recommendations differ with regard to timing of treatment (i.e. timing of initiation in low-risk patients or discontinuation in high-risk patients) and procalcitonin cut-off points for the recommendation/strong recommendation to discontinue antibiotics (≤ 0.25/≤ 0.1 µg/L in ED and inpatients, ≤ 0.5/≤ 0.25 µg/L in ICU patients, and reduction by ≥ 80% from peak levels in sepsis patients). Expert commentary: Our proposed algorithms may facilitate safe and efficient implementation of procalcitonin-guided antibiotic protocols in diverse healthcare settings. Still, the decision about initiation and cessation of antibiotic treatment remains a clinical decision based on the patient assessment and the severity of illness and use of procalcitonin should not delay empirical treatment in high risk situations.

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