Procalcitonin-guided antibiotic discontinuation in ventilator-associated pneumonia: a prospective observational study

Background: Procalcitonin (PCT), an important biomarker, can be used for the guidance of antibiotic therapy in respiratory infection. However, it has been a problem that some patients might need antibiotic therapy restart because of infection recurrence after antibiotic discontinuation. To date, there are very few literature on the study of risk factors accounting for infection recurrence. Purpose of this clinical study: 1) To study on antibiotic discontinuation in ventilator-associated pneumonia (VAP) under the guidance of PCT; 2) To evaluate the possible risk factors leading to infection recurrence and antibiotic reuse. Methods: Antibiotic discontinuation was performed when patients met the following criteria: (i) serum PCT<0.5 μg/L, (ii) temperature<38.5℃ and (iii) leukocyte count<15×10(9)/L. Next, the patients were divided into infection recurrence group (infection recurring within 7 days after antibiotic discontinuation) or infection controlled group (no infection recurring after antibiotic discontinuation). Possible risk factors accounting for infection recurrence were evaluated using logistic regression analysis. Results: Of the eligible 51 patients with VAP, 20 patients suffered infection recurrence. Clinical pulmonary infection score (CPIS) and characteristics of tracheal secretions were the independent risk factors (P=0.045 and P=0.041, respectively), accounting for infection recurrence. Simplified CPIS≥5 served a certain predictive value for infection recurrence in VAP when physicians considered antibiotic discontinuation (The area under the receiver operating characteristic curve 0.781, specificity 90.3%, sensitivity 55.0%, positive predictive value 78.6% and negative predictive value 75.7%). At the time of antibiotic discontinuation, differences between the two groups were not statistically significant in the proportion of patients with a tracheotomy and in the culture results of endotracheal aspirates (including semi-quantitative results and whether pathogens were multidrug-resistant [MDR] strains). Conclusion: Simplified CPIS and characteristics of tracheal secretions can be used to predict infection recurrence following PCT-guided antibiotic discontinuation in VAP. These findings are important because physicians may not need to put too much care on semi-quantitative culture results of endotracheal aspirates and whether pathogens are MDRstrains. Trial registration: The registration number of this clinical trial is: ChiCTR-OPC-17011228 (Trial registry name: Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn).