Beishuizen, Albertus

de Jong, Evelien

de Lange, Dylan W.

Nijsten, Maarten W.

van Oers, Jos A. H.

English

Dissertations of the University of Groningen

   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 01-11-2023International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, influences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a significant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inflammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and specificity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo financial or non-financial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efficacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

Why would procalcitonin perform better in patients with a SOFA-score less than 8?

University of Groningen

   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 13-01-2020International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, inﬂuences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a signiﬁcant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inﬂammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and speciﬁcity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo ﬁnancial or non-ﬁnancial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efﬁcacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, influences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a significant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inflammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and specificity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo financial or non-financial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efficacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

van Oers, Jos A H

Nijsten, Maarten W

de Lange, Dylan W

Utrecht University Repository

   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 05-06-2022International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, influences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a significant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inflammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and specificity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo financial or non-financial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efficacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

ARTS repository - University of Groningen

   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 07-06-2022International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, influences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a significant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inflammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and specificity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo financial or non-financial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efficacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

Proceedings - University of Groningen

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   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 11-09-2023International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, influences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a significant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inflammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and specificity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo financial or non-financial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efficacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

   University of GroningenWhy would procalcitonin perform better in patients with a SOFA-score less than 8?van Oers, Jos A. H.; Nijsten, Maarten W.; de Jong, Evelien; Beishuizen, Albertus; de Lange,Dylan W.Published in:International Journal of Infectious DiseasesDOI:10.1016/j.ijid.2019.09.027IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2019Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Oers, J. A. H., Nijsten, M. W., de Jong, E., Beishuizen, A., & de Lange, D. W. (2019). Why wouldprocalcitonin perform better in patients with a SOFA-score less than 8? International Journal of InfectiousDiseases, 89, 185-186. https://doi.org/10.1016/j.ijid.2019.09.027CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 11-12-2022International Journal of Infectious Diseases 89 (2019) 185–186Letter to the EditorContents lists available at ScienceDirectInternational Journal of Infectious Diseasesjournal home page: www.elsevier .com/ locat e/ i j idWhy would procalcitonin perform better inpatients with a SOFA-score less than 8?We read with great interest the meta-analysis by Peng andcolleagues published in the International Journal of InfectiousDiseases, in which they questioned the effectiveness of procalci-tonin (PCT)-guided antibiotic therapy (Peng et al., 2019). Theycombined 16 randomized controlled trials (RCT), including 6452critically ill patients with infections, and concluded that PCT-guided antibiotic therapy does not lead to a decreased short-termmortality. They also concluded that PCT-guided cessation ofantibiotics only reduces short-term mortality in patients with aSequential Organ Failure Assessment (SOFA) score of <8. It was,therefore, suggested that PCT-guided antibiotic therapy would bebetter suited to patients without multiple organ failure in theemergency department or general ward. Unfortunately, we thinkthat this conclusion is neither correctly derived from the availabledata nor plausible!The question regarding whether the severity of illness, asmeasured by the SOFA score, influences the effect of antibiotictreatment in all RCTs on PCT-guided therapy, is a valid researchquestion. However, analyses should have been done at theindividual patient level. Indeed, a recent patient-level meta-analysis on PCT-guided antibiotic therapy in 4482 septic patients inthe intensive care unit (ICU), by Wirz and colleagues, showed that30-day mortality was lower in the PCT-guided group (Wirz et al.,2018). Furthermore, when patients were divided into threesubgroups by organ failure (SOFA 0 to 6, 7 to 10, and 10 to 24),the effects on mortality persisted. In our SAPS-trial on PCTguidance (De Jong et al., 2016), we included 1546 ICU patients andwe demonstrated a significant reduction in 28-day mortality in thePCT group (p = 0.007). This effect on mortality persisted in the 587patients with a SOFA score of 8 (p = 0.024).Moreover, why should PCT-guided antibiotic therapy be bettersuited to patients in the emergency department and general wardor only patients with a SOFA score of <8? Obviously there arenumerous non-infectious inflammatory processes, e.g. trauma orsurgery, in which PCT can be elevated. Such conditions arefrequently seen in emergency departments and general wards, butcan also be encountered in the ICU. These conditions were wellbalanced between the two groups in previous meta-analyses. Wetherefore conclude that antibiotics should be started when aninfection is suspected and that PCT is particularly suited for thecessation of antibiotic treatment, and we want to warn care-giversthat the sensitivity and specificity of a single PCT measurement inhttps://doi.org/10.1016/j.ijid.2019.09.0271201-9712/© 2019 The Author(s). Published by Elsevier Ltd on behalf of International Solicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).Downloaded for Anonymous User (n/a) at University of GroningFor personal use only. No other uses without permissionthe emergency department, general ward, or ICU are not highenough to start or withhold antibiotics based on PCT alone.Author contributionsAll authors (JvO, MN, EdJ, BB, and DL) made equal contributions.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialNot applicable.Competing interestsNo financial or non-financial competing interests.FundingNo funding.ReferencesDe Jong E, van Oers JA, Beishuizen B, Vos P, Vermeijden WJ, Haas LE, et al. Efficacyand safety of procalcitonin guidance in reducing the duration of antibiotictreatment in critically ill patients: a randomized controlled, open-label trial.Lancet infect Dis 2016;16:819–27.Peng F, Chang W, Xie JF, Sun Q, Qiu HB, Yang Y. Ineffectiveness of procalcitonin-guided antibiotic therapy in severely ill patients: a meta-analysis. Int J Infect Dis2019;85:158–66.Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolf M, Chastre J, et al. Effect ofprocalcitonin-guided antibiotic treatment on clinical outcomes in intensivecare unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018;22:191.Jos A.H. van Oers*Department of Intensive Care Medicine, Elisabeth TweestedenZiekenhuis, Tilburg, The NetherlandsMaarten W. NijstenDepartment of Critical Care, University Medical Center Groningen,University of Groningen, The Netherlandsciety for Infectious Diseases. This is an open access article under the CC BY-NC-NDen from ClinicalKey.com by Elsevier on December 23, 2019.. Copyright ©2019. Elsevier Inc. All rights reserved.186 Letter to the Editor / International Journal of Infectious Diseases 89 (2019) 185–186Evelien de JongDepartment of Intensive Care Medicine, Rode Kruis Ziekenhuis,Beverwijk, The NetherlandsAlbertus BeishuizenDepartment of Intensive Care Medicine, Medisch Spectrum Twente,Enschede, The NetherlandsDylan W. de LangeDepartment of Intensive Care Medicine, University Medical CentreUtrecht, Utrecht, The Netherlands* Corresponding author at: Department of Intensive Care Medi-cine, Elisabeth Tweesteden Ziekenhuis, PO Box 90151, 5000 LCDownloaded for Anonymous User (n/a) at University of GroningeFor personal use only. No other uses without permission.Tilburg, The Netherlands.E-mail addresses: jah.vanoers@etz.nl (J. van Oers),m.w.n.nijsten@umcg.nl (M. Nijsten),edejong@rkz.nl (E. de Jong),B.Beishuizen@mst.nl (A. Beishuizen),D.W.deLange@umcutrecht.nl (D. de Lange).Corresponding Editor: Eskild Petersen, Aarhus, DenmarkReceived 9 September 2019n from ClinicalKey.com by Elsevier on December 23, 2019. Copyright ©2019. Elsevier Inc. All rights reserved.

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Why would procalcitonin perform better in patients with a SOFA-score less than 8?

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