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BMC Emergency Medicine
Published in: BMC Emergency Medicine 1/2016

Open Access 01-12-2016 | Study protocol

Higher diagnostic accuracy and cost-effectiveness using procalcitonin in the treatment of emergency medicine patients with fever (The HiTEMP study): a multicenter randomized study

Authors: Yuri van der Does, Maarten Limper, Stephanie C. E. Schuit, Marten J. Poley, Joost van Rosmalen, Christian Ramakers, Peter Patka, Eric C. M. van Gorp, Pleunie P. M. Rood

Published in: BMC Emergency Medicine | Issue 1/2016

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Abstract

Background

Fever is a common symptom in the emergency department(ED). Fever can be caused by bacterial infections, which are treated with antibiotics. Often, bacterial infections cannot be ruled out in the ED using standard diagnostics, and empiric antibiotic treatment is started. Procalcitonin(PCT) is a biomarker for bacterial infections, but its role in an undifferentiated ED population remains unclear. We hypothesize that PCT-guided therapy may reduce antibiotics prescription in undifferentiated febrile ED patients. The primary objectives of this study are to determine a) the efficacy, b) the safety of PCT-guided therapy, and c) the accuracy of the biomarker PCT for bacterial infections. The secondary objective is to study the cost-effectiveness of PCT-guided therapy.

Methods/design

This is a multicenter noninferiority randomized controlled trial. All adult ED patients with fever(≥38.2 °C) are randomized between standard care with and without the addition of a PCT level, after written informed consent.
a)
For efficacy, the reduction of patients receiving antibiotics is calculated, using a superiority analysis: differences between the PCT-guided group and control group are assessed using a Fisher’s exact test, and a multivariable logistic regression analysis to account for the effects of demographic and medical variables on the percentage of febrile patients receiving antibiotics.
 
b)
Safety consists of a composite endpoint, defined as mortality, intensive care admission and ED return visit within 14 days. Noninferiority of PCT will be tested using a one-sided 95 % confidence interval for the difference in the composite safety endpoint between the PCT-guided and control groups using a noninferiority margin of 7.5 %.
 
c)
Accuracy of PCT and CRP for the diagnosis of bacterial infections will be reported, using the sensitivity, specificity, and the area under the receiver-operating-characteristic curve in the definitive diagnosis of bacterial infections.
 
The sample size is 550 patients, which was calculated using a power analysis for all primary objectives. Enrollment of patients started in August 2014 and will last 2 years.

Discussion

PCT may offer a more tailor-made treatment to the individual ED patient with fever. Prospective costs analyses will reveal the economic consequences of implementing PCT-guided therapy in the ED.

This trial is registered in the Dutch trial register

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Metadata
Title
Higher diagnostic accuracy and cost-effectiveness using procalcitonin in the treatment of emergency medicine patients with fever (The HiTEMP study): a multicenter randomized study
Authors
Yuri van der Does
Maarten Limper
Stephanie C. E. Schuit
Marten J. Poley
Joost van Rosmalen
Christian Ramakers
Peter Patka
Eric C. M. van Gorp
Pleunie P. M. Rood
Publication date
01-12-2016
Publisher
BioMed Central
Published in
BMC Emergency Medicine / Issue 1/2016
Electronic ISSN: 1471-227X
DOI
https://doi.org/10.1186/s12873-016-0081-6

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