An algorithm for PCT-guided antimicrobial therapy: a consensus statement by Japanese experts

In Japan, a national antimicrobial resistance (AMR) action plan was adopted in 2016, advocating a 20% reduction in antibiotic consumption by 2020. However, there is still room for improvement to accomplish this goal. Many randomized controlled trials have reported that procalcitonin (PCT)-guided antimicrobial therapy could help to reduce antibiotic consumption without negative health effects, specifically in acute respiratory infections. In September 2018, some experts in Europe and the USA proposed algorithms for PCT-guided antimicrobial therapy in mild to moderate infection cases outside the ICU and severe cases in the ICU (the international experts consensus). Thereafter, a group of Japanese experts, including specialists in intensive care medicine, emergency medicine, respiratory medicine and infectious diseases, created a modified version of a PCT-guided algorithm (Japanese experts consensus). This modified algorithm was adapted to better fit Japanese medical circumstances, since PCT-guided therapy is not widely used in daily clinical practice in Japan. The Japanese algorithm has three specific characteristics. First, the target patients are limited to only hospitalized ICU or non-ICU patients. Second, pneumonia due to Pseudomonas aeruginosa, Staphylococcus aureus and Legionella species are excluded. Finally, a different timing of PCT follow-up measurement was proposed to meet restrictions of the Japanese medical insurance system. The adapted algorithms has high potential to further improve the safe reduction in antibiotic consumption in Japan, while reducing the spread of AMR pathogens.

Is antipseudomonal antibiotic treatment needed for all nursing and healthcare-associated pneumonia patients at risk for antimicrobial resistance?

OBJECTIVES

Nursing and healthcare-associated pneumonia (NHCAP) was proposed by the Japanese Respiratory Society to refer to healthcare-associated pneumonia. This study aimed to investigate whether antipseudomonal antibiotic therapy improved the prognosis of NHCAP patients at high risk for antimicrobial-resistant pathogens.

METHODS

Consecutive hospitalised NHCAP patients in Kurashiki Central Hospital between October 2010 and December 2016 were prospectively enrolled. NHCAP patients who were at high risk for antimicrobial resistance were defined as those who received antimicrobials in the preceding 90 days and/or were on tube feeding. The patients who received antipseudomonal antibiotics were defined as the guideline-concordant (GC) therapy group, and the others were defined as the guideline-discordant (GD) therapy group. The primary outcome was 30-day mortality. Inverse probability of treatment weighting (IPTW) analysis was used to reduce biases.

RESULTS

There were 277 patients with NHCAP; a majority (78.0%) were discharged from a hospital in the preceding 90 days. There were 52 patients in the GC group and 225 patients in the GD group. The 30-day mortality rate was significantly higher in the GC group than in the GD group (17.3%, 9/52 vs. 7.1%, 16/225; P = 0.03). After IPTW analysis, the GC therapy, compared with GD therapy, did not improve the 30-day mortality (OR 1.71, 95% CI 0.65-4.47; P = 0.28).

CONCLUSIONS

Not all NHCAP patients, even those at high risk for antimicrobial resistance, need antipseudomonal antimicrobial treatment. The treatment strategy for NHCAP patients should be individualised, according to the pneumonia severity, risk for antimicrobial-resistant pathogens, and antibiogram in each hospital.