Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection.

BACKGROUND: The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. METHODS: In 14 U.S. hospitals with high adherence to quality measures for the treatment of pneumonia, we provided guidance for clinicians about national clinical practice recommendations for the treatment of lower respiratory tract infections and the interpretation of procalcitonin assays. We then randomly assigned patients who presented to the emergency department with a suspected lower respiratory tract infection and for whom the treating physician was uncertain whether antibiotic therapy was indicated to one of two groups: the procalcitonin group, in which the treating clinicians were provided with real-time initial (and serial, if the patient was hospitalized) procalcitonin assay results and an antibiotic use guideline with graded recommendations based on four tiers of procalcitonin levels, or the usual-care group. We hypothesized that within 30 days after enrollment the total antibiotic-days would be lower - and the percentage of patients with adverse outcomes would not be more than 4.5 percentage points higher - in the procalcitonin group than in the usual-care group. RESULTS: A total of 1656 patients were included in the final analysis cohort (826 randomly assigned to the procalcitonin group and 830 to the usual-care group), of whom 782 (47.2%) were hospitalized and 984 (59.4%) received antibiotics within 30 days. The treating clinician received procalcitonin assay results for 792 of 826 patients (95.9%) in the procalcitonin group (median time from sample collection to assay result, 77 minutes) and for 18 of 830 patients (2.2%) in the usual-care group. In both groups, the procalcitonin-level tier was associated with the decision to prescribe antibiotics in the emergency department. There was no significant difference between the procalcitonin group and the usual-care group in antibiotic-days (mean, 4.2 and 4.3 days, respectively; difference, -0.05 day; 95% confidence interval [CI], -0.6 to 0.5; P=0.87) or the proportion of patients with adverse outcomes (11.7% [96 patients] and 13.1% [109 patients]; difference, -1.5 percentage points; 95% CI, -4.6 to 1.7; P<0.001 for noninferiority) within 30 days. CONCLUSIONS: The provision of procalcitonin assay results, along with instructions on their interpretation, to emergency department and hospital-based clinicians did not result in less use of antibiotics than did usual care among patients with suspected lower respiratory tract infection. (Funded by the National Institute of General Medical Sciences; ProACT ClinicalTrials.gov number, NCT02130986 .).

Procedural Competency in Academic Emergency Medicine Attending Physicians: How Is Competency Maintained and Evaluated by Academic Institutions in the US?

Introduction There have been numerous studies examining the minimum graduation requirements for resident training of procedural skills within Emergency Medicine programs; however, how academic medical centers in the United States maintain Emergency Medicine attending procedural skill competency has not been explored. Objectives The aim of this study was to examine the processes in place to evaluate and track the procedural skills practices of Emergency Medicine attending physicians at academic institutions in the US. Methods An exploratory cross-sectional survey was sent to all 39 ACGME-accredited Emergency Medicine programs in the US through a REDCap survey in 2020. Survey items inquired about the current methods in place to maintain competence on 13 procedural skills performed by Emergency Medicine providers. Results The survey response rate was 26.9%. The majority of programs did not have a process in place to evaluate procedural skills at the time of initial appointment (74.3%), and almost half of participating programs reported no formalized process during employment (51.3%). Institutions reported no minimum required number for the following procedures: dislocation reduction, intraosseous placement, lateral canthotomy, lumbar puncture, paracentesis, pericardiocentesis, thoracentesis, transvenous cardiac pacing, and tube thoracostomy. For central venous access, cricothyrotomy, endotracheal intubation, and procedural sedation, 25.6% or less of institutions had minimum annual requirements. Conclusion This study summarized the current methods in place to assess Emergency Medicine attending procedural skills at US academic institutions and demonstrated that the majority of programs lack a formalized method to assess attending procedural competency. Further research is needed to determine the value and benefit of different methods available for procedural skill competency assessment. It is believed that preventing procedural skill decay in attending physicians by a standardized process has the potential to improve patient outcomes, reduce costs and complication rates, and improve physician self-esteem, well-being, and confidence.