Procalcitonin-based algorithm reduces unnecessary antibiotic use in acute pancreatitis

A procalcitonin-guided algorithm could reduce the unnecessary use of antibiotics in patients with acute pancreatitis, according to results of the PROCAP trial.

“PROCAP met its primary endpoint; antibiotic use was significantly less in patients having a procalcitonin-guided algorithm to guide their antibiotic use,” presented Professor Ajith Siriwardena from the Manchester Royal Infirmary, Manchester, UK, at UEG 2022.

The single-centre, patient-blinded trial, conducted at the Manchester Royal Infirmary, involved 260 adults with acute pancreatitis who were randomized 1:1 to procalcitonin algorithm-guided care (n=132) or usual care (n=128). Procalcitonin testing was carried out on days 0, 4, and 7, and then weekly. Patients with a test value of <1.0 ng/mL were to stop or not initiate antibiotic therapy, while those with a test value of ≥1.0 ng/mL were to initiate or continue antibiotics.

The use of antibiotics during index hospitalization was significantly lower among patients assigned to the procalcitonin-guided vs usual care group (45 percent vs 62 percent; adjusted risk difference, –15.6 percent, 95 percent confidence interval, –27.0 to –4.2 percent; p=0.0071). [UEG 2022, abstract LB04]

The reduced use of antibiotics in the procalcitonin-guided group persisted after excluding mandated prophylactic antibiotic use (31 percent vs 47 percent; adjusted difference, –14.2 percent; p=0.0061).

Patients in the procalcitonin-guided group had fewer days on antibiotic therapy than those in the usual care group (mean 4.5 vs 5.8 days; adjusted difference, –1.16; p=0.015).

Number of clinical infections did not significantly differ between patients in the procalcitonin-guided and usual care group (mean 0.39 vs 0.27; adjusted difference, 0.046; p=0.50), nor did the number of hospital-acquired infections (mean 0.24 vs 0.11; adjusted difference, –0.005; p=0.84) or duration of hospitalization (mean 13.6 vs 10.7 days; adjusted difference, 0.9; p=0.28).

There were four and three deaths in the procalcitonin-guided and usual care group, respectively, all of which were related to underlying severe pancreatitis (3 percent vs 2 percent; adjusted difference, 0.69 percent; p=0.73). Adverse event incidence did not differ between groups.

“International guidelines recommend against the use of antibiotics in acute pancreatitis in the absence of specific infection,” said Siriwardena. “However, globally, there is an overuse of antibiotics in all forms of acute pancreatitis and at all stages because of the difficulty in distinguishing between a systemic inflammatory response and infection.”

The normal physiologic levels of procalcitonin are low, increase in response to infection, and decrease after infection eradication, he continued.  

“Our findings suggest that procalcitonin-guided care can reduce antibiotic use without increasing infection or harm in patients with acute pancreatitis. Procalcitonin-based algorithms to guide antibiotic use should be considered in the care of this group of patients and be incorporated into future guidelines on the management of acute pancreatitis,” he concluded.