In Sepsis: Procalcitonin-Guided Antibiotic Stewardship in Surgical Patients: A Systematic Review

Abstract

Background: Surgical patients with sepsis frequently require early empirical antimicrobial therapy, but prolonged or unnecessary antibiotic exposure contributes to antimicrobial resistance, adverse drug events, secondary infections, and increased healthcare costs. Differentiating persistent bacterial infection from sterile postoperative inflammation remains difficult because conventional inflammatory markers often lack specificity in surgical and critical care settings. Procalcitonin-guided antibiotic stewardship has been proposed as a biomarker-supported strategy to optimize antibiotic discontinuation and de-escalation. Objective: This systematic review aimed to evaluate whether procalcitonin-guided antibiotic stewardship reduces unnecessary antimicrobial exposure without compromising clinical safety among adult surgical or surgically relevant critically ill patients with sepsis. Methods: A systematic literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Library, Embase, and additional sources for literature published from 2022 to 2026. Eligible records evaluated procalcitonin-guided antibiotic discontinuation, de-escalation, or stewardship in adult sepsis, surgical sepsis, postoperative infection, intra-abdominal infection, acute pancreatitis, cancer-associated sepsis, or critically ill populations relevant to surgical decision-making. Findings were synthesized narratively because of heterogeneity in study design, populations, thresholds, algorithms, and outcome reporting. Results: Fourteen records were included, comprising randomized controlled trials, a pre–post implementation study, systematic reviews/meta-analyses, narrative and stewardship reviews, consensus guidance, and cost-effectiveness evidence. The most consistent finding was reduced antibiotic duration or antimicrobial exposure with procalcitonin-guided strategies. Mortality and clinical safety findings were generally reassuring, but direct surgical-specific evidence remained limited. Evidence for ICU or hospital length of stay, antimicrobial resistance, and cost-effectiveness was less consistent and largely indirect. Conclusion: Procalcitonin-guided stewardship may support earlier antibiotic discontinuation and reduce unnecessary antimicrobial exposure in sepsis care, but in surgical patients it should be used as an adjunct to clinical judgment, source-control assessment, microbiology, imaging, and serial clinical evaluation. Surgical-specific randomized trials are needed to define optimal thresholds, timing, safety outcomes, resistance effects, and economic value.