Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection

Differentiating acute bacterial infection from other causes of lower respiratory tract illness is challenging. In this trial, procalcitonin was investigated as a point-of-care test to aid in determining whether antibiotics were needed in the treatment of these illnesses.

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Vydáno v:	The New England journal of medicine Ročník 379; číslo 3; s. 236 - 249
Hlavní autoři:	Huang, David T, Yealy, Donald M, Filbin, Michael R, Brown, Aaron M, Chang, Chung-Chou H, Doi, Yohei, Donnino, Michael W, Fine, Jonathan, Fine, Michael J, Fischer, Michelle A, Holst, John M, Hou, Peter C, Kellum, John A, Khan, Feras, Kurz, Michael C, Lotfipour, Shahram, LoVecchio, Frank, Peck-Palmer, Octavia M, Pike, Francis, Prunty, Heather, Sherwin, Robert L, Southerland, Lauren, Terndrup, Thomas, Weissfeld, Lisa A, Yabes, Jonathan, Angus, Derek C
Médium:	Journal Article
Jazyk:	angličtina
Vydáno:	United States Massachusetts Medical Society 19.07.2018
Témata:	Adult Aged Anti-Bacterial Agents - therapeutic use Antibiotics Bacterial Infections - blood Bacterial Infections - diagnosis Bacterial Infections - drug therapy Biomarkers - blood Calcitonin - blood Chronic obstructive pulmonary disease Emergency medical care Emergency Service, Hospital Emergency services FDA approval Female Guideline Adherence Hospitalists Hospitals Humans Illnesses Inappropriate Prescribing - prevention & control Inappropriate Prescribing - statistics & numerical data Infections Male Medicine Middle Aged Patients Pneumonia Pneumonia - drug therapy Practice Guidelines as Topic Practice Patterns, Physicians' - statistics & numerical data Procalcitonin Respiratory tract diseases Respiratory tract infection Respiratory Tract Infections - blood Respiratory Tract Infections - drug therapy Viral infections United States > US Detroit Michigan Pittsburgh Pennsylvania
ISSN:	0028-4793, 1533-4406, 1533-4406
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Abstract	Differentiating acute bacterial infection from other causes of lower respiratory tract illness is challenging. In this trial, procalcitonin was investigated as a point-of-care test to aid in determining whether antibiotics were needed in the treatment of these illnesses.
AbstractList	The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear.BACKGROUNDThe effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear.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.METHODSIn 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.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.RESULTSA 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.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 .).CONCLUSIONSThe 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 .). The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. 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. 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. 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 .). Differentiating acute bacterial infection from other causes of lower respiratory tract illness is challenging. In this trial, procalcitonin was investigated as a point-of-care test to aid in determining whether antibiotics were needed in the treatment of these illnesses. 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.)
Author	Filbin, Michael R Pike, Francis Southerland, Lauren Kellum, John A Fine, Jonathan Huang, David T LoVecchio, Frank Doi, Yohei Donnino, Michael W Angus, Derek C Fischer, Michelle A Hou, Peter C Chang, Chung-Chou H Prunty, Heather Peck-Palmer, Octavia M Sherwin, Robert L Lotfipour, Shahram Fine, Michael J Yabes, Jonathan Terndrup, Thomas Weissfeld, Lisa A Holst, John M Khan, Feras Brown, Aaron M Yealy, Donald M Kurz, Michael C
Author_xml	– sequence: 1 givenname: David T surname: Huang fullname: Huang, David T organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 2 givenname: Donald M surname: Yealy fullname: Yealy, Donald M organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 3 givenname: Michael R surname: Filbin fullname: Filbin, Michael R organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 4 givenname: Aaron M surname: Brown fullname: Brown, Aaron M organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 5 givenname: Chung-Chou H surname: Chang fullname: Chang, Chung-Chou H organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 6 givenname: Yohei surname: Doi fullname: Doi, Yohei organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 7 givenname: Michael W surname: Donnino fullname: Donnino, Michael W organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 8 givenname: Jonathan surname: Fine fullname: Fine, Jonathan organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 9 givenname: Michael J surname: Fine fullname: Fine, Michael J organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 10 givenname: Michelle A surname: Fischer fullname: Fischer, Michelle A organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 11 givenname: John M surname: Holst fullname: Holst, John M organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 12 givenname: Peter C surname: Hou fullname: Hou, Peter C organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 13 givenname: John A surname: Kellum fullname: Kellum, John A organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 14 givenname: Feras surname: Khan fullname: Khan, Feras organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 15 givenname: Michael C surname: Kurz fullname: Kurz, Michael C organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 16 givenname: Shahram surname: Lotfipour fullname: Lotfipour, Shahram organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 17 givenname: Frank surname: LoVecchio fullname: LoVecchio, Frank organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 18 givenname: Octavia M surname: Peck-Palmer fullname: Peck-Palmer, Octavia M organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 19 givenname: Francis surname: Pike fullname: Pike, Francis organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 20 givenname: Heather surname: Prunty fullname: Prunty, Heather organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 21 givenname: Robert L surname: Sherwin fullname: Sherwin, Robert L organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 22 givenname: Lauren surname: Southerland fullname: Southerland, Lauren organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 23 givenname: Thomas surname: Terndrup fullname: Terndrup, Thomas organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 24 givenname: Lisa A surname: Weissfeld fullname: Weissfeld, Lisa A organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 25 givenname: Jonathan surname: Yabes fullname: Yabes, Jonathan organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.) – sequence: 26 givenname: Derek C surname: Angus fullname: Angus, Derek C organization: From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center (D.T.H., C.-C.H.C., J.A.K., O.M.P.-P., D.C.A.), the Departments of Critical Care Medicine (D.T.H., J.A.K., O.M.P.-P., D.C.A.), Emergency Medicine (D.T.H., D.M.Y., A.M.B., H.P.), and Pathology (O.M.P.-P.), the MACRO (Multidisciplinary Acute Care Research Organization) Center (D.T.H., D.M.Y., D.C.A.), and the Divisions of General Internal Medicine (C.-C.H.C., M.J.F., J.Y.) and Infectious Diseases (Y.D.), University of Pittsburgh, and the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System (M.J.F.) — all in Pittsburgh; the Department of Emergency Medicine, Massachusetts General Hospital (M.R.F.), the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (M.W.D.), and the Department of Emergency Medicine, Brigham and Women’s Hospital (P.C.H.) — all in Boston; the Department of Emergency Medicine, Norwalk Hospital, Norwalk, CT (J.F.); the Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA (M.A.F., T.T.); the Department of Emergency Medicine, Essentia Health, Duluth, MN (J.M.H.); the Department of Emergency Medicine, University of Maryland Medical Center, Baltimore (F.K.); the Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Birmingham (M.C.K.); the Department of Emergency Medicine, University of California at Irvine Medical Center, Irvine (S.L.); the Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ (F.L.); Eli Lilly, Indianapolis (F.P.); the Department of Emergency Medicine, Detroit Receiving Hospital, Detroit (R.L.S.); the Department of Emergency Medicine, Ohio State University, Columbus (L.S., T.T.); and Statistics Collaborative, Washington, DC (L.A.W.)
BackLink	https://www.ncbi.nlm.nih.gov/pubmed/29781385$$D View this record in MEDLINE/PubMed
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Snippet	Differentiating acute bacterial infection from other causes of lower respiratory tract illness is challenging. In this trial, procalcitonin was investigated as... The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. In 14 U.S. hospitals with high... Background The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear. Methods In 14 U.S.... The effect of procalcitonin-guided use of antibiotics on treatment for suspected lower respiratory tract infection is unclear.BACKGROUNDThe effect of...
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SubjectTerms	Adult Aged Anti-Bacterial Agents - therapeutic use Antibiotics Bacterial Infections - blood Bacterial Infections - diagnosis Bacterial Infections - drug therapy Biomarkers - blood Calcitonin - blood Chronic obstructive pulmonary disease Emergency medical care Emergency Service, Hospital Emergency services FDA approval Female Guideline Adherence Hospitalists Hospitals Humans Illnesses Inappropriate Prescribing - prevention & control Inappropriate Prescribing - statistics & numerical data Infections Male Medicine Middle Aged Patients Pneumonia Pneumonia - drug therapy Practice Guidelines as Topic Practice Patterns, Physicians' - statistics & numerical data Procalcitonin Respiratory tract diseases Respiratory tract infection Respiratory Tract Infections - blood Respiratory Tract Infections - drug therapy Viral infections
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Title	Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection
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