Although 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.