• Simon W Lam, Seth R Bauer, Robert Fowler, and Abhijit Duggal.
• Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
• Crit. Care Med. 2018 May 1; 46 (5): 684-690.

ObjectiveNumerous studies have evaluated the use of procalcitonin guidance during different phases of antibiotics management (initiation, cessation, or a combination of both) in patients admitted to ICUs. Several meta-analyses have attempted to generate an overall effect of procalcitonin-guidance on patient outcomes. However, combining studies from different phases of antibiotics management may not be appropriate due to the risk of clinical heterogeneity. The purpose of this systematic review and meta-analysis was to evaluate the effect of procalcitonin-guided strategies in different phases of antibiotics use.Data SourcesWe searched MEDLINE and EMBASE from inception until November 1, 2017.Study SelectionWe included randomized controlled trials that evaluated procalcitonin guidance compared with usual care for management of antibiotics in critically ill adult patients.Data ExtractionWe extracted study details, patient characteristics, procalcitonin algorithm, and outcomes.Data SynthesisWe included 15 studies, from 1,624 abstracts identified based on our search strategy (three initiation, nine cessation, and three mixed). The pooled risk ratio for short-term mortality for the initiation, cessation, and mixed procalcitonin strategies were 1.00 (95% CI, 0.86-1.15,;p = 0.91), 0.87 (95% CI, 0.77-0.98; p = 0.02), and 1.01 (95% CI, 0.80-1.29; p = 0.93), respectively. Procalcitonin for cessation and mixed strategies was associated with decrease antibiotics duration (-1.26 d [p < 0.001] and -3.10 d [p =0.04], respectively). No differences were observed in other outcome measures.ConclusionWhen evaluating all studies of procalcitonin-guided antibiotics management in critically ill patients, no difference in short-term mortality was observed. However, when only examining procalcitonin-guided cessation of antibiotics, lower mortality was detected. Future studies should focus specifically on procalcitonin for the cessation of antibiotics in critically ill patients.

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