• Nishkantha Arulkumaran, Muska Khpal, Karen Tam, Aravindhan Baheerathan, Carlos Corredor, and Mervyn Singer.
• Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom.
• Crit. Care Med. 2020 May 1; 48 (5): 757-764.

ObjectiveTo investigate methods of antibiotic duration minimization and their effect on mortality and infectious complications in critically ill patients.Data SourcesA systematic search of PubMed, Embase (via Ovid), clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials (via Wiley) (CENTRAL, Issue 2, 2015).Study SelectionRandomized clinical trials comparing strategies to minimize antibiotic duration (days) for patients with infections or sepsis in intensive care.Data ExtractionA systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. Dichotomous data are presented as relative risk (95% CIs) and p value, and continuous data are presented as mean difference (CI) and p value.Data SynthesisWe included 22 randomized clinical trials (6,046 patients). Strategies to minimize antibiotic use included procalcitonin (14 randomized clinical trials), clinical algorithms (two randomized clinical trials), and fixed-antibiotic duration (six randomized clinical trials). Procalcitonin (-1.23 [-1.61 to -0.85]; p < 0.001), but not clinical algorithm-guided antibiotic therapy (-7.41 [-18.18 to 3.37]; p = 0.18), was associated with shorter duration of antibiotic therapy. The intended reduction in antibiotic duration ranged from 3 to 7 days in fixed-duration antibiotic therapy randomized clinical trials. Neither procalcitonin-guided antibiotic treatment (0.91 [0.82-1.01]; p = 0.09), clinical algorithm-guided antibiotic treatment (0.67 [0.30-1.54]; p = 0.35), nor fixed-duration antibiotics (1.21 [0.90-1.63]; p = 0.20) were associated with reduction in mortality. Z-curve for trial sequential analyses of mortality associated with procalcitonin-guided therapy did not reach the trial sequential monitoring boundaries for benefit, harm, or futility (adjusted CI, 0.72-1.10). Trial sequential analyses for mortality associated with clinical algorithm and fixed-duration treatment accumulated less than 5% of the required information size. Despite shorter antibiotic duration, neither procalcitonin-guided therapy (0.93 [0.84-1.03]; p = 0.15) nor fixed-duration antibiotic therapy (1.06 [0.74-1.53]; p = 0.75) was associated with treatment failure.ConclusionsAlthough the duration of antibiotic therapy is reduced with procalcitonin-guided therapy or prespecified limited duration, meta-analysis and trial sequential analyses are inconclusive for mortality benefit. Data on clinical algorithms to guide antibiotic cessation are limited.

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