Procalcitonin-Guided Antibiotic Discontinuation in ICU Sepsis: Effects on Duration and Mortality – A Systematic Review

Abstract

Background: Sepsis remains a leading cause of morbidity and mortality in intensive care units (ICUs), where early empirical antibiotic therapy is essential for survival. However, prolonged antibiotic exposure contributes to antimicrobial resistance and high mortality. Procalcitonin (PCT) has emerged as a promising biomarker to guide antibiotic discontinuation and optimise antimicrobial stewardship in ICU patients with sepsis. This systematic review evaluates the effectiveness of PCT-guided antibiotic discontinuation in reducing antibiotic duration and its impact on mortality outcomes among adult ICU patients with sepsis.

Methods: A systematic search was conducted on three databases: PubMed, Medline via Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) between March and April 2025. Randomised controlled trials (RCTs) published in English within the past 10 years were included if they evaluated PCT-guided antibiotic discontinuation in adult ICU patients with sepsis and reported outcomes on antibiotic duration and mortality. The methodological quality of the included studies was appraised using the Mixed Methods Appraisal Tool (2018).

Results: Eight RCTs comprising 6,043 adult ICU patients met the inclusion criteria. Six studies demonstrated statistically significant reductions in antibiotic duration in the PCT-guided groups, particularly those incorporating daily PCT testing and clear discontinuation thresholds. Two large multicentre RCTs reported significant reductions in short-term mortality, while others found non-inferior outcomes. One study focusing on cancer ICU patients reported increased mortality, highlighting the need for caution in immunocompromised populations.

Conclusion: PCT-guided antibiotic discontinuation appears to be an effective and generally safe strategy for reducing antibiotic exposure in ICU sepsis patients. However, mortality benefits remain inconsistent may be influenced by patient risk profiles and adherence to PCT protocols. Further large-scale .trials with standardised PCT algorithms are warranted