Excluding infection through procalcitonin testing improves outcomes of congestive heart failure patients presenting with acute respiratory symptoms: Results from the randomized ProHOSP trial

• Published in: International journal of cardiology Vol. 175; no. 3; pp. 464 - 472
• Main Authors: Schuetz, Philipp, Kutz, Alexander, Grolimund, Eva, Haubitz, Sebastian, Demann, Désirée, Vögeli, Alaadin, Hitz, Fabienne, Christ-Crain, Mirjam, Thomann, Robert, Falconnier, Claudine, Hoess, Claus, Henzen, Christoph, Marlowe, Robert J, Zimmerli, Werner, Mueller, Beat
• Format: Journal Article
• Language: English
• Published: Shannon Elsevier 20.08.2014
• Subjects: Aged; Aged, 80 and over; Anti-Bacterial Agents - therapeutic use; Antibacterial agents; Antibiotics. Antiinfectious agents. Antiparasitic agents; Biological and medical sciences; Biomarkers - blood; Calcitonin - blood; Calcitonin Gene-Related Peptide; Cardiology. Vascular system; Cardiovascular; Female; Heart; Heart Failure - blood; Heart Failure - drug therapy; Heart Failure - epidemiology; Heart failure, cardiogenic pulmonary edema, cardiac enlargement; Humans; Male; Medical sciences; Middle Aged; Pharmacology. Drug treatments; Prospective Studies; Protein Precursors - blood; Respiratory Tract Infections - blood; Respiratory Tract Infections - drug therapy; Respiratory Tract Infections - epidemiology; Switzerland - epidemiology; Treatment Outcome; CHF; PCT; OR; CI; Antibiotic therapy; procalcitonin; emergency room; odds ratio; SD; Biomarkers in Acute Heart Failure trial; LRTI; congestive heart failure; lower respiratory infection; BACH; confidence interval; ICU; intensive care unit; Differential diagnosis; acute heart failure; Antibiotic stewardship; AHF; ED; standard deviation; Prognosis; Procalcitonin; Cardiovascular disease; Respiratory system; Result; Respiratory tract; Improvement; Heart disease; Clinical trial; Evolution; Cardiology; Human; Heart failure; Acute; Patient; Medical screening; Differential diagnostic; Infection; Symptomatology; Antibiotic; Treatment; Acute heart failure; Antibacterial agent; Inaugural sign
• DOI: 10.1016/j.ijcard.2014.06.022
• ISSN: 0167-5273

Abstract Background/objectives We sought to determine whether exclusion of infection and antibiotic stewardship with the infection biomarker procalcitonin improves outcomes in congestive heart failure (CHF) patients presenting to emergency departments with respiratory symptoms and suspicion of respiratory infection. Methods We performed a secondary analysis of patients with a past medical history of CHF formerly included in a Swiss multicenter randomized-controlled trial. The trial compared antibiotic stewardship according to a procalcitonin algorithm or state-of-the-art guidelines (controls). The primary endpoint was a 30-day adverse outcome (death, intensive care unit admission); the secondary endpoints included a 30-day antibiotic exposure. Results In the 110/233 analyzed patients (47.2%) with low initial procalcitonin (< 0.25 μg/L), suggesting the absence of systemic bacterial infection, those randomized to procalcitonin guidance (n = 50) had a significantly lower adverse outcome rate compared to controls (n = 60): 4% vs. 20% (absolute difference − 16.0%, 95% confidence interval (CI) − 28.4% to − 3.6%, P = 0.01), and significantly reduced antibiotic exposure [days] (mean 3.7 ± 4.0 vs. 6.5 ± 4.4, difference − 2.8 [95% CI, − 4.4 to − 1.2], P < 0.01). When initial procalcitonin was ≥ 0.25 μg/L, procalcitonin-guided patients had significantly reduced antibiotic exposure due to early stop of therapy without any difference in adverse outcomes (25.8% vs. 24.6%, difference [95% CI] 1.2% [− 14.5% to 16.9%, P = 0.88]). Conclusions CHF patients presenting to the emergency department with respiratory symptoms and suspicion for respiratory infection had decreased antibiotic exposure and improved outcomes when procalcitonin measurement was used to exclude bacterial infection and guide antibiotic treatment. These data provide further evidence for the potential harmful effects of antibiotic / fluid treatment when used instead of diuretics and heart failure medication in clinically symptomatic CHF patients without underlying infection.