Procalcitonin and Lung Ultrasonography Guided Antibiotherapy in Emergency Departments

NCT ID: NCT05463406

Last Updated: 2025-04-10

Basic Information

• Recruitment Status: ACTIVE_NOT_RECRUITING
• Clinical Phase: NA
• Total Enrollment: 1440 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2022-12-05
• Study Completion Date: 2025-05-16

Brief Summary

Acute respiratory infections are a common reason of attendance at emergency departments. It is also the main reason of unnecessary antibiotic prescription. Antibiotics save lives, but can also directly harm patients by causing antibiotic-associated adverse events. Antibiotic use is directly related to resistance, which is one of the major threats of our century. In addition, some microorganisms live in and on the human body and promote many aspects of our health. Antibiotic treatment can disturb those microorganisms and therefore have long-lasting negative effects on our health.

Unfortunately, it is difficult to differentiate between viral infections, which usually heal spontaneously, and bacterial pneumonia, which needs antibiotics treatment. This is one of the reasons of this over-prescribing of antibiotics.

This project aims to reduce widespread use of antibiotics in the emergency department through a new diagnostic strategy of bacterial pneumonia. This strategy includes sequential use of well-known techniques: a clinical score, lung ultrasound and finally a biomarker, procalcitonin. The latter tends to be higher in bacterial infections. The combination of these different tests improves the diagnostic process and allows improved use of targeted antibiotics, with the ultimate goal of better patient management.

The study will compare the antibiotic prescription rate and the clinical course of patients managed using this new diagnostic approach with those managed as usual. The project will also evaluate the acceptability and feasibility of this strategy and its cost-effectiveness. These two aspects are essential for a wider implementation of this innovative diagnostic approach and decrease antibiotic resistance.

Detailed Description

Background Community-acquired lower respiratory tract infections (LRTI) are one of the most common motivations for emergency department (ED) consultations and stands as the leading cause of inappropriate antibiotic prescription. Besides the side effects, antibiotic overuse alters the microbiome and generates antibiotic resistance. When assessing patients with LRTIs, the challenge for ED physicians is to identify those with community-acquired pneumonia (CAP) of bacterial origin, who will most likely benefit from antibiotics. The low diagnostic accuracy of existing tools, as well as the poor adherence of clinicians to test guidance are leading causes of inappropriate antibiotic use.

Several diagnostic tests can assist in identifying patients with LRTI who require antibiotics. Clinical prediction score can refine the probability of CAP. Lung ultrasound (LUS) has a better diagnostic performance than chest X-ray, the historic reference imaging modality to consolidation in ED. LUS is performed quickly at the bedside without radiation. Procalcitonin (PCT) is a host inflammatory biomarker which tends to be higher in bacterial infections. PCT can be used safely to guide antibiotics use, while its impact on prescription is controversial. None of these tools on its own is sufficient to optimize antibiotic prescription, while a combined approach could better guide clinicians.

Rationale The investigators propose to evaluate the use of a decision support tool to guide antibiotics use in the ED as the summative value of LUS with PCT remains unknown in this setting.

Pragmatic stepped-wedge cluster-randomized controlled clinical trial investigating a new algorithm combining a clinical score, LUS and PCT results (The PLUS algorithm) for the management of LRTIs among adults in EDs. The unit of randomization will be the ED.

Primary safety objective To demonstrate non-inferiority of the intervention in terms of clinical failure by day 28.

Co-primary efficacy objective To show a 15% reduction in the proportion of patients with LRTIs prescribed an antibiotic by day 28 in the intervention group compared with the usual care group.

Secondary objectives

1. To compare the quality of life (bothersomeness of CAP-related symptoms) on day 7, day 28 and day 90 between patients in the intervention and control groups.

2. To evaluate the acceptability and feasibility of the intervention through the identification of barriers and facilitators in patients and physicians.

3. To assess the incremental cost-effectiveness of the intervention as compared to usual care using a within-trial (short-term), and a model-based (long-term) economic evaluation.

4. To develop an advanced automatic LUS image analysis method using machine learning to assist in LUS diagnosis and risk stratification.

Conditions

Lower Respiratory Tract Infection

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: SEQUENTIAL
• Primary Study Purpose: DIAGNOSTIC
• Blinding Strategy: NONE

Study Groups

The PLUS algorithm

The PLUS clinical management algorithm:

EDs having switched to the intervention period (intervention group) will manage their patients using the PLUS algorithm.

The PLUS algorithm starts with a validated pneumonia clinical prediction score (score of Van Vugt), followed by LUS. In case of positive results of any of these tests, PCT is measured to identify patients who will most likely benefit from antibiotics. A validated clinical severity score will ensure the safety of the intervention in those with discordant results (LUS consolidation and low PCT).

Group Type: EXPERIMENTAL

The PLUS algorithm

Intervention Type: OTHER

Combination of a clinical prediction score and LUS, and if needed PCT measurement

Usual care

Usual care: management as usual

Group Type: OTHER

Usual care

Intervention Type: OTHER

Management as usual

Interventions

The PLUS algorithm

Combination of a clinical prediction score and LUS, and if needed PCT measurement

Intervention Type: OTHER

Usual care

Management as usual

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• Signed informed consent
• Patients aged 18 years or more
• Acute LRTI (acute illness, less than 21 days, with at least one lower respiratory tract symptom, i.e. cough, sputum, dyspnea, chest pain and no alternative explanation)
• At least one of the following clinical criteria:

• Focal abnormal auscultation (decreased breath sounds, crackles, bronchial breath sounds)
• Fever (documented temperature ≥ 38°C in the last 24 hours, including self-measured temperature ≥ 38°C)
• Tachypnea (respiratory rate ≥ 22/minute)
• Tachycardia (heart rate ≥ 100/minute)

Exclusion Criteria

• Previous receipt of a quinolone, macrolide or ceftriaxone or, of more than one dose of any other antibiotic within 72h prior to enrolment (excepted prophylactic antibiotics or antibiotics given for urinary tract infection)
• Previous hospital stay in the last 14 days
• Cystic fibrosis
• Severe COPD (≥GOLD 3 or if not available, as a proxy: exacerbation treated with antibiotics during the last 6 months)
• Severe immunodeficiency (drug-induced neutropenia with <500 neutrophils/mm3, HIV infection with CD4<200 cells/mm3, solid organ or bone marrow transplant recipient, prednisone ≥ 20mg/day for >28 days)
• Initial admission of the patient in the intensive care unit
• Microbiologically-documented SARS-CoV-2
• Incapacity of discernment

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Cantonal Hospital of St. Gallen

OTHER

Sponsor Role: collaborator

University Hospital, Basel, Switzerland

OTHER

Sponsor Role: collaborator

Kantonsspital Baden

OTHER

Sponsor Role: collaborator

Hôpital Intercantonal de la Broye, Payerne, Switzerland

UNKNOWN

Sponsor Role: collaborator

Réseau Hospitalier Neuchâtelois

OTHER

Sponsor Role: collaborator

Hôpital Riviera-Chablais, Vaud-Valais

OTHER

Sponsor Role: collaborator

Luzerner Kantonsspital

OTHER

Sponsor Role: collaborator

Cantonal Hosptal, Baselland

OTHER

Sponsor Role: collaborator

St. Claraspital AG

OTHER

Sponsor Role: collaborator

Dr Boillat-Blanco Noemie

OTHER

Sponsor Role: lead

Responsible Party

Dr Boillat-Blanco Noemie

Sponsor and National coordinating investigator

Responsibility Role: SPONSOR_INVESTIGATOR

Locations

Cantonal hospital of Baden

Baden, Canton of Aargau, Switzerland

University Hospital of Basel

Basel, Canton of Basel-City, Switzerland

Kantonsspital Baselland

Liestal, Canton of Basel-City, Switzerland

Luzerner Kantonsspital

Lucerne, Canton of Lucerne, Switzerland

Réseau Hospitalier Neuchâtelois

Neuchâtel, Canton of Neuchâtel, Switzerland

Cantonal Hospital of St. Gallen

Sankt Gallen, Canton of St. Gallen, Switzerland

Centre hospitalier universitaire vaudois (CHUV)

Lausanne, Canton of Vaud, Switzerland

Hôpital Intercantonal de la Broye

Payerne, Canton of Vaud, Switzerland

Hôpital Riviera-Chablais

Rennaz, Canton of Vaud, Switzerland

Countries

Switzerland

References

Lamping DL, Schroter S, Marquis P, Marrel A, Duprat-Lomon I, Sagnier PP. The community-acquired pneumonia symptom questionnaire: a new, patient-based outcome measure to evaluate symptoms in patients with community-acquired pneumonia. Chest. 2002 Sep;122(3):920-9. doi: 10.1378/chest.122.3.920.

Reference Type: BACKGROUND

PMID: 12226033 (View on PubMed)

Lhopitallier L, Kronenberg A, Meuwly JY, Locatelli I, Mueller Y, Senn N, D'Acremont V, Boillat-Blanco N. Procalcitonin and lung ultrasonography point-of-care testing to determine antibiotic prescription in patients with lower respiratory tract infection in primary care: pragmatic cluster randomised trial. BMJ. 2021 Sep 21;374:n2132. doi: 10.1136/bmj.n2132.

Reference Type: BACKGROUND

PMID: 34548312 (View on PubMed)

Lhopitallier L, Kronenberg A, Meuwly JY, Locatelli I, Dubois J, Marti J, Mueller Y, Senn N, D'Acremont V, Boillat-Blanco N. Procalcitonin and lung ultrasonography point-of-care testing to decide on antibiotic prescription in patients with lower respiratory tract infection in primary care: protocol of a pragmatic cluster randomized trial. BMC Pulm Med. 2019 Aug 6;19(1):143. doi: 10.1186/s12890-019-0898-3.

Reference Type: BACKGROUND

PMID: 31387559 (View on PubMed)

Bessat C, Bingisser R, Schwendinger M, Bulaty T, Fournier Y, Della Santa V, Pfeil M, Schwab D, Leuppi JD, Geigy N, Steuer S, Roos F, Christ M, Sirova A, Espejo T, Riedel H, Atzl A, Napieralski F, Marti J, Cisco G, Foley RA, Schindler M, Hartley MA, Fayet A, Garcia E, Locatelli I, Albrich WC, Hugli O, Boillat-Blanco N; PLUS-IS-LESS study group. PLUS-IS-LESS project: Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments: study protocol for a pragmatic stepped-wedge cluster-randomized trial. Trials. 2024 Jan 25;25(1):86. doi: 10.1186/s13063-023-07795-y.

Reference Type: DERIVED

PMID: 38273319 (View on PubMed)

Other Identifiers

SNSF 33IC30_201300

Identifier Type: OTHER_GRANT

Identifier Source: secondary_id

PLUS-IS-LESS

Identifier Type: -

Identifier Source: org_study_id