University of Groningen
Why would procalcitonin perform better in patients with a SOFA-score less than 8?
van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,
Dylan W.
Published in:
International Journal of Infectious Diseases
DOI:
10.1016/j.ijid.2019.09.027
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Publication date:
2019
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Citation for published version (APA):
van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why would
procalcitonin perform better in patients with a SOFA-score less than 8? International Journal of Infectious
Diseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027
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Letter
to
the
Editor
Whywouldprocalcitoninperformbetterin patientswithaSOFA-scorelessthan8?
We read withgreat interest the meta-analysisby Peng and colleagues published in the International Journal of Infectious Diseases,inwhichthey questionedtheeffectivenessof procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). They combined16randomizedcontrolledtrials(RCT),including6452 critically ill patients with infections, and concluded that PCT-guidedantibiotictherapydoesnotleadtoadecreasedshort-term mortality. They also concluded that PCT-guided cessation of antibioticsonlyreducesshort-termmortalityinpatientswitha SequentialOrganFailureAssessment(SOFA)scoreof<8.Itwas, therefore,suggestedthatPCT-guidedantibiotictherapywouldbe bettersuited topatients without multipleorgan failure in the emergencydepartmentorgeneralward.Unfortunately,wethink thatthisconclusionisneithercorrectlyderivedfromtheavailable datanorplausible!
The question regarding whether the severity of illness, as measuredbythe SOFA score,influences the effectof antibiotic treatmentinallRCTsonPCT-guided therapy,isavalidresearch question. However, analyses should have been done at the individual patient level. Indeed, a recent patient-level meta-analysisonPCT-guidedantibiotictherapyin4482septicpatientsin theintensivecareunit(ICU),byWirzandcolleagues,showedthat 30-daymortalitywaslowerinthePCT-guidedgroup(Wirzetal., 2018). Furthermore, when patients were divided into three subgroupsbyorganfailure(SOFA0to6,7to10, and10to24), the effects on mortality persisted. In our SAPS-trial on PCT guidance(DeJongetal.,2016),weincluded1546ICUpatientsand wedemonstratedasignificantreductionin28-daymortalityinthe PCTgroup(p=0.007).Thiseffectonmortalitypersistedinthe587 patientswithaSOFAscoreof8(p=0.024).
Moreover,whyshouldPCT-guidedantibiotictherapybebetter suitedtopatientsintheemergencydepartmentandgeneralward oronly patientswitha SOFA scoreof <8? Obviously thereare numerousnon-infectiousinflammatoryprocesses,e.g.traumaor surgery, in which PCT can be elevated. Such conditions are frequentlyseeninemergencydepartmentsandgeneralwards,but canalsobeencounteredintheICU.Theseconditionswerewell balancedbetweenthetwogroupsinpreviousmeta-analyses.We therefore conclude that antibiotics should bestarted when an infectionis suspectedandthatPCT isparticularlysuitedforthe cessationofantibiotictreatment,andwewanttowarncare-givers thatthesensitivityandspecificityofasinglePCTmeasurementin
the emergency department, general ward, or ICU are not high enoughtostartorwithholdantibioticsbasedonPCTalone. Authorcontributions
Allauthors(JvO,MN,EdJ,BB,andDL)madeequalcontributions. Ethicsapprovalandconsenttoparticipate
Notapplicable. Consentforpublication
Notapplicable.
Availabilityofdataandmaterial Notapplicable.
Competinginterests
Nofinancialornon-financialcompetinginterests. Funding
Nofunding. References
DeJongE,vanOersJA,BeishuizenB,VosP,VermeijdenWJ,HaasLE,etal.Efficacy andsafetyofprocalcitoninguidanceinreducingtheduration ofantibiotic treatmentincriticallyillpatients:arandomizedcontrolled,open-labeltrial. LancetinfectDis2016;16:819–27.
PengF,ChangW,XieJF,SunQ,QiuHB,YangY.Ineffectivenessof procalcitonin-guidedantibiotictherapyinseverelyillpatients:ameta-analysis.IntJInfectDis 2019;85:158–66.
Wirz Y,Meier MA, Bouadma L, Luyt CE, WolfM, ChastreJ, et al. Effect of procalcitonin-guidedantibiotictreatmentonclinicaloutcomesinintensive careunitpatientswithinfectionandsepsispatients:apatient-level meta-analysisofrandomizedtrials.CritCare2018;22:191.
JosA.H.vanOers*
DepartmentofIntensiveCareMedicine,ElisabethTweesteden Ziekenhuis,Tilburg,TheNetherlands MaartenW.Nijsten DepartmentofCriticalCare,UniversityMedicalCenterGroningen, UniversityofGroningen,TheNetherlands
https://doi.org/10.1016/j.ijid.2019.09.027
1201-9712/©2019TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
InternationalJournalofInfectiousDiseases89(2019)185–186
ContentslistsavailableatScienceDirect
International
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Infectious
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EveliendeJong DepartmentofIntensiveCareMedicine,RodeKruisZiekenhuis, Beverwijk,TheNetherlands AlbertusBeishuizen DepartmentofIntensiveCareMedicine,MedischSpectrumTwente, Enschede,TheNetherlands DylanW.deLange DepartmentofIntensiveCareMedicine,UniversityMedicalCentre Utrecht,Utrecht,TheNetherlands *Correspondingauthorat:DepartmentofIntensiveCare Medi-cine,ElisabethTweestedenZiekenhuis,POBox90151,5000LC
Tilburg,TheNetherlands. E-mailaddresses:jah.vanoers@etz.nl(J.vanOers),
m.w.n.nijsten@umcg.nl(M.Nijsten),
edejong@rkz.nl(E.deJong),
B.Beishuizen@mst.nl(A.Beishuizen),
D.W.deLange@umcutrecht.nl(D.deLange). CorrespondingEditor:EskildPetersen,Aarhus,Denmark Received9September2019
186 LettertotheEditor/InternationalJournalofInfectiousDiseases89(2019)185–186
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