Objective To assess whether point-of care procalcitonin and lung ultrasonography can safely reduce unnecessary antibiotic treatment in patients with lower respiratory tract infections in primary care. Design Three group, pragmatic cluster randomised controlled trial from September 2018 to March 2020. Setting 60 Swiss general practices. Participants One general practitioner per practice was included. General practitioners screen all patients with acute cough; patients with clinical pneumonia were included. Interventions Randomisation in a 1:1:1 of general practitioners to either antibiotics guided by sequential procalcitonin and lung ultrasonography point-of-care tests (UltraPro; n=152), procalcitonin guided antibiotics (n=195), or usual care (n=122). Main outcomes Primary outcome was proportion of patients in each group prescribed an antibiotic by day 28. Secondary outcomes included duration of restricted activities due to lower respiratory tract infection within 14 days. Results 60 general practitioners included 469 patients (median age 53 years (interquartile range 38-66); 278 (59%) were female). Probability of antibiotic prescription at day 28 was lower in the procalcitonin group than in the usual care group (0.40 v 0.70, cluster corrected difference −0.26 (95% confidence interval −0.41 to −0.10)). No significant difference was seen between UltraPro and procalcitonin groups (0.41 v 0.40, −0.03 (−0.17 to 0.12)). The median number of days with restricted activities by day 14 was 4 days in the procalcitonin group and 3 days in the usual care group (difference 1 day (95% confidence interval −0.23 to 2.32); hazard ratio 0.75 (95% confidence interval 0.58 to 0.97)), which did not prove non-inferiority. Conclusions Compared with usual care, point-of-care procalcitonin led to a 26% absolute reduction in the probability of 28 day antibiotic prescription without affecting patients’ safety. Point-of-care lung ultrasonography did not further reduce antibiotic prescription, although a potential added value cannot be excluded, owing to the wide confidence intervals. Trial registration ClinicalTrials.gov [NCT03191071][1]. All relevant data are available via the Zenodo repository (10.5281/zenodo.4032527). [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03191071&atom=%2Fbmj%2F374%2Fbmj.n2132.atom

中文翻译：

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降钙素原和肺超声床旁检测以确定初级保健中下呼吸道感染患者的抗生素处方：务实的整群随机试验

目的 评估床旁降钙素原和肺部超声检查是否可以安全地减少初级保健中下呼吸道感染患者不必要的抗生素治疗。设计三组、实用的整群随机对照试验，时间为 2018 年 9 月至 2020 年 3 月。设置 60 个瑞士一般实践。参与者 每个实践包括一名全科医生。全科医生筛查所有急性咳嗽患者；包括临床肺炎患者。干预措施 以 1:1:1 的比例将全科医生随机分配到由连续降钙素原和肺超声检查床旁检测 (UltraPro; n=152) 指导的抗生素、降钙素原指导的抗生素 (n=195) 或常规护理 (n =122)。主要结果 主要结果是到第 28 天时每组中开具抗生素的患者比例。次要结果包括 14 天内因下呼吸道感染而限制活动的持续时间。结果 60 名全科医生包括 469 名患者（中位年龄 53 岁（四分位距 38-66）；278 名（59%）为女性）。降钙素原组在第 28 天开具抗生素处方的概率低于常规护理组（0.40 v 0.70，聚类校正差异 -0.26（95% 置信区间 -0.41 至 -0.10））。UltraPro 和降钙素原组之间未观察到显着差异（0.41 v 0.40，-0.03（-0.17 至 0.12））。到第 14 天活动受限的中位天数在降钙素原组为 4 天，在常规护理组为 3 天（差异 1 天（95% 置信区间 -0. 23 至 2.32)；风险比 0.75（95% 置信区间 0.58 至 0.97）），这并未证明非劣效性。结论 与常规护理相比，床旁降钙素原可在不影响患者安全的情况下，使 28 天抗生素处方的概率绝对降低 26%。床旁肺部超声检查并未进一步减少抗生素处方，但由于置信区间较宽，不能排除潜在的附加价值。试验注册 ClinicalTrials.gov [NCT03191071][1]。所有相关数据均可通过 Zenodo 存储库 (10.5281/zenodo.4032527) 获得。[1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03191071&atom=%2Fbmj%2F374%2Fbmj.n2132.atom 结论 与常规护理相比，床旁降钙素原可在不影响患者安全的情况下，使 28 天抗生素处方的概率绝对降低 26%。床旁肺部超声检查并未进一步减少抗生素处方，但由于置信区间较宽，不能排除潜在的附加价值。试验注册 ClinicalTrials.gov [NCT03191071][1]。所有相关数据均可通过 Zenodo 存储库 (10.5281/zenodo.4032527) 获得。[1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03191071&atom=%2Fbmj%2F374%2Fbmj.n2132.atom 结论 与常规护理相比，床旁降钙素原可在不影响患者安全的情况下，使 28 天抗生素处方的概率绝对降低 26%。床旁肺部超声检查并未进一步减少抗生素处方，但由于置信区间较宽，不能排除潜在的附加价值。试验注册 ClinicalTrials.gov [NCT03191071][1]。所有相关数据均可通过 Zenodo 存储库 (10.5281/zenodo.4032527) 获得。[1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03191071&atom=%2Fbmj%2F374%2Fbmj.n2132.atom 床旁肺部超声检查并未进一步减少抗生素处方，但由于置信区间较宽，不能排除潜在的附加价值。试验注册 ClinicalTrials.gov [NCT03191071][1]。所有相关数据均可通过 Zenodo 存储库 (10.5281/zenodo.4032527) 获得。[1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03191071&atom=%2Fbmj%2F374%2Fbmj.n2132.atom 床旁肺部超声检查并未进一步减少抗生素处方，但由于置信区间较宽，不能排除潜在的附加价值。试验注册 ClinicalTrials.gov [NCT03191071][1]。所有相关数据均可通过 Zenodo 存储库 (10.5281/zenodo.4032527) 获得。[1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03191071&atom=%2Fbmj%2F374%2Fbmj.n2132.atom