Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit
(ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment
and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim
was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in
critically ill patients.We searched databases CENTRAL, Embase and Medline. We included
randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with
SOC reporting on length of AB therapy, mortality, recurrent and secondary infection,
ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes
in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3
definition. In the statistical analysis, a random-effects model was used to pool effect
sizes.We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison
with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79
days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day
mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was
more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly
higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant
difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and
hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95%
CI: - 3.13, 0.67, respectively).PCT-guided AB therapy may be associated with reduced
AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and
hospital length of stay. Our results render the need for better designed studies investigating
the role of PCT-guided AB stewardship in critically ill patients.
