To combat antimicrobial resistance (AMR), advocates have called for passage of the Pioneering Antimicrobial Subscriptions To End Upsurging Resistance (PASTEUR) Act in the United States, which would appropriate $6 billion in new taxpayer-funded subsidies for antibiotic development. However, the number of antibiotics in clinical development, and US Food and Drug Administration approvals of new antibiotics, have already markedly increased in the last 15 years. Thus, instead of focusing on more economic subsidies, we recommend reducing selective pressure driving AMR by (1) establishing pay-for-performance mechanisms that disincentivize overprescribing of antibiotics, (2) focusing existing research and development funding on strategies that decrease reliance on antibiotics, and (3) changing regulation or law to require specialized training in antibiotic stewardship for a clinician to be able to prescribe new antibiotics that target unmet AMR need. To stabilize the antibiotic market, we recommend (1) establishment of an advisory board of clinical practitioners to more accurately target existing antibiotic incentives and (2) endowment of nonprofit companies that sustainably self-fund antibiotic discovery, creating a bench of molecules that can be partnered with industry at later stages of development.

The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.

Web ExclusivesMarch 2022Annals On Call - Procalcitonin in the Diagnosis of Bacterial InfectionFREERobert M. Centor, MD and David N. Gilbert, MDRobert M. Centor, MDHuntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Search for more papers by this author and David N. Gilbert, MDProvidence Medical Center, Portland, Oregon (D.N.G.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/A21-0006 CME/MOC SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In this episode of Annals On Call, Dr. Centor discusses the use of procalcitonin in the diagnosis of pneumonia with Dr. David Gilbert.Annals articles discussed include...Annals for Hospitalists Inpatient Notes - A Critical Look at Procalcitonin Testing in Pneumonia: https://www.acpjournals.org/doi/10.7326/M21-1913About Annals On CallAnnals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery.For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall. Comments0 CommentsSign In to Submit A Comment Christine Laine, MD, MPHAnnals of internal Medicine, American College of Physicians5 August 2022 Response to Dr. Frick In response to Dr. Frick, note that disclosures of interest are available on Annals.org for every Annals on Call podcast by clicking the link under the podcast title. Disclosures: Dr. Laine is Editor in Chief, Annals of Internal Medicine and a full time employee of the American College of Physicians. Fred W Frick,MD,FACPCommunity Physicians of Indiana1 August 2022 Podcast on procalcitonin I would like Dr. Centor to take another look at procalcitonin. Some investigators, with no financial conflict with the owners of the procalcitonin test, have come to different conclusions. I am not implying that the podcast guest had any conflicts (I don't recall, was there a disclosure?), but a significant portion of the literature favorable to the test comes from investigators with financial conflicts. Author, Article, and Disclosure InformationAffiliations: Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Providence Medical Center, Portland, Oregon (D.N.G.)Disclosures: Dr. Centor reports consulting fees from DynaMed and employment with the U.S. Department of Veterans Affairs. Dr. Gilbert reports research grants from BioFire, consulting fees from bioMérieux, and participation as chair of the data safety monitoring board for Leonard-Meron Biosciences. All relevant financial relationships have been mitigated. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=A21-0006.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he is employed at Johns Hopkins University. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center and consultancy with Boston Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports employment with the Perelman School of Medicine, University of Pennsylvania, and consultancies with the U.S. Food and Drug Administration and the State of Colorado.This article was published at Annals.org on 1 March 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - A Critical Look at Procalcitonin Testing in Pneumonia Michael S. Pulia and Peter K. Lindenauer Metrics March 2022Volume 175, Issue 3Page: OC1 ePublished: 1 March 2022 Issue Published: March 2022 CopyrightCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...

The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has -appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.

The interpretation of serum procalcitonin (PCT) levels in septic patients is facilitated by reviewing the known stimuli that activate the PCT family of genes. Herein we describe 7 pathways that, alone or in combination, can increase serum PCT levels. As a marker of activation of innate immunity, high PCT levels affect clinical diagnosis, can be trended as a measure of "source" control, and can guide duration of antibacterial therapy in septic patients. Low PCT levels reflect little to no activation of an innate immune response, influence the differential diagnosis, and support the discontinuation of empiric antibiotic therapy. Understanding the pathways that result in elevated serum PCT levels is necessary for interpretation and subsequent clinical management.

Background: Although most observational studies identify viral or bacterial pathogens in 50% or less of patients hospitalized with community-acquired pneumonia (CAP), we previously demonstrated that a multi-test bundle (MTB) detected a potential pathogen in 73% of patients. This study compares detection rates for potential pathogens with the MTB versus the Biofire (R) Pneumonia FilmArray (R) panel (BPFA) multiplex PCR platform and presents an approach for integrating BPFA results as a foundation for subsequent antibiotic stewardship (AS) activities. Methods: Between January 2017 to March 2018, all patients admitted for CAP were enrolled. Patients were considered evaluable if all elements of the MTB and the BPFA were completed, and they met other a priori inclusion criteria. The primary endpoint was the percentage of potential pathogens detected using the MTB (8 viral and 6 bacterial targets) versus the BPFA (8 viral and 18 bacterial targets). Blood and sputum cultures were performed on all patients. Two or more procalcitonin (PCT) levels assisted clinical assessments as to whether detected bacteria were invading or colonizing. Results: Of 585 enrolled patients, 274 were evaluable. A potential viral pathogen was detected in 40.5% with MTB versus 60.9% of patients with BPFA with an odds ratio (95% CI) of 9.00 (4.12 to 23.30) p<0.01. A potential bacterial pathogen was identified in 66.4% with the MTB vs 75.5% with the BPFA odds ratio (95% CI) of 2.09 (1.24 to 3.59), p 0.003). Low PCT levels helped identify detected bacteria as colonizers. (C) 2020 Elsevier Inc. All rights reserved.

Department of Medical Education, Providence Portland Medical Center, Portland, OR *See also p. e470. Dr. Gilbert has disclosed that he does not have any potential conflicts of interest.

Ideas and Opinions15 October 2019Ensuring Sustainability of Needed Antibiotics: Aiming for the DART BoardBrad Spellberg, MD, Travis B. Nielsen, PhD, David N. Gilbert, MD, Andrew F. Shorr, MD, MPH, MBA, and Eric P. Brass, MD, PhDBrad Spellberg, MDLos Angeles County and University of Southern California Medical Center, Los Angeles, California (B.S.)Search for more papers by this author, Travis B. Nielsen, PhDStritch School of Medicine and Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois (T.B.N.)Search for more papers by this author, David N. Gilbert, MDProvidence Portland Medical Center and University of Oregon Health Sciences School of Medicine, Portland, Oregon (D.N.G.)Search for more papers by this author, Andrew F. Shorr, MD, MPH, MBAPulmonary and Critical Care Medicine Service, MedStar Washington Hospital Center, Washington, DC (A.F.S.)Search for more papers by this author, and Eric P. Brass, MD, PhDDavid Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California (E.P.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-1893 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The initial boom of antibiotic discovery led experts in the late 1940s to predict the end of bacterial infections as a threat (1). However, by 1965, the pipeline collapsed, leaving physicians desperate for new antibiotics “to overcome the problems of resistance…against gram-negative bacillary infections…and better ones against mycobacteria” (2). These threats from a half-century ago, which are eerily similar to those today, underscore that the crisis of antibiotic resistance is neither unprecedented nor unexpected. It is recurrent and foreseeable.Years of advocacy to combat the latest crisis led to the establishment of economic incentives to support antibiotic research and development. ...References1. Johnson AS. Medicine's responsibility in the propagation of poor protoplasm. N Engl J Med. 1948;238:755-8. [PMID: 18860758] CrossrefMedlineGoogle Scholar2. Finland M, Kirby WM, Chabbert YA, et al. Round table: are new antibiotics needed? Antimicrob Agents Chemother (Bethesda). 1965;5:1107-14. [PMID: 5883409] MedlineGoogle Scholar3. Nielsen TB, Brass EP, Gilbert DN, et al. Sustainable discovery and development of antibiotics—is a nonprofit approach the future? N Engl J Med. 2019;381:503-5. [PMID: 31216396] doi:10.1056/NEJMp1905589 CrossrefMedlineGoogle Scholar4. Infectious Diseases Society of America. White paper: recommendations on the conduct of superiority and organism-specific clinical trials of antibacterial agents for the treatment of infections caused by drug-resistant bacterial pathogens. Clin Infect Dis. 2012;55:1031-46. [PMID: 22891041] CrossrefMedlineGoogle Scholar5. U.S. Food and Drug Administration. Generating Antibiotic Incentives Now. Accessed at www.fda.gov/media/110982/download on 1 August 2019. Google Scholar6. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Antibiotic resistant threats in the United States, 2013. Accessed at www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf on 1 August 2019. Google Scholar7. World Health Organization. Global priority list of antibiotic-resistant bacteria to guide research, discovery, and development of new antibiotics. Accessed at www.who.int/medicines/publications/WHO-PPL-Short_Summary_25Feb-ET_NM_WHO.pdf on 1 August 2019. Google Scholar8. Spellberg B, Bartlett JG, Gilbert DN. The future of antibiotics and resistance. N Engl J Med. 2013;368:299-302. [PMID: 23343059] doi:10.1056/NEJMp1215093 CrossrefMedlineGoogle Scholar9. Spellberg B, Srinivasan A, Chambers HF. New societal approaches to empowering antibiotic stewardship. JAMA. 2016;315:1229-30. [PMID: 26914942] doi:10.1001/jama.2016.1346 CrossrefMedlineGoogle Scholar10. Angus D, Alexander B, Berry S, et al. Adaptive Platform Trials Coalition. Adaptive platform trials: definition, design, conduct and reporting considerations. Nat Rev Drug Discov. 2019. [PMID: 31462747] doi:10.1038/s41573-019-0034-3 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Los Angeles County and University of Southern California Medical Center, Los Angeles, California (B.S.)Stritch School of Medicine and Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois (T.B.N.)Providence Portland Medical Center and University of Oregon Health Sciences School of Medicine, Portland, Oregon (D.N.G.)Pulmonary and Critical Care Medicine Service, MedStar Washington Hospital Center, Washington, DC (A.F.S.)David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California (E.P.B.)Grant Support: By grants R01 AI130060, R01 AI117211, and R42 AI106375 from the National Institute of Allergy and Infectious Diseases at the National Institutes of Health and by grant R01 HS025690 from the Agency for Healthcare Research and Quality.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1893.Corresponding Author: Brad Spellberg, MD, Los Angeles County and University of Southern California Medical Center, 2051 Marengo Street, Los Angeles, CA 90033; e-mail, [email protected]lacounty.gov.Current Author Addresses: Dr. Spellberg: Los Angeles County and University of Southern California Medical Center, 2051 Marengo Street, C2K126, Los Angeles, CA 90033.Dr. Nielsen: 421 Beloit Avenue, Apt 1, Forest Park, IL 60130.Dr. Gilbert: Providence Portland Medical Center and University of Oregon Health Sciences School of Medicine, 5050 Northeast Hoyt Street, Suite 540, Portland, OR 97213.Dr. Shorr: MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010.Dr. Brass: 70 Sea Breeze Avenue, Rancho Palos Verdes, CA 90275.Author Contributions: Conception and design: B. Spellberg, T.B. Nielsen, D.N. Gilbert, E.P. Brass.Analysis and interpretation of the data: D.N. Gilbert, A.F. Shorr.Drafting of the article: B. Spellberg, T.B. Nielsen, A.F. Shorr, E.P. Brass.Critical revision of the article for important intellectual content: B. Spellberg, T.B. Nielsen, D.N. Gilbert, A.F. Shorr, E.P. Brass.Final approval of the article: B. Spellberg, T.B. Nielsen, D.N. Gilbert, A.F. Shorr, E.P. Brass.Administrative, technical, or logistic support: B. Spellberg.Collection and assembly of data: T.B. Nielsen.This article was published at Annals.org on 8 October 2019. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byA Nonprofit Drug Development Model Is Part of the Antimicrobial Resistance (AMR) SolutionMonoclonal Antibody Requires Immunomodulation for Efficacy Against Acinetobacter baumannii InfectionNIMble innovation—a networked model for public antibiotic trialsMethodological and Reporting Quality of Noninferiority Randomized Controlled Trials Comparing Antibiotic Therapies: A Systematic ReviewAlignment With Market Forces: The “Re-Whithering” of Infectious DiseasesEvaluating for-profit public benefit corporations as an additional structure for antibiotic development and commercialization 15 October 2019Volume 171, Issue 8Page: 580-582KeywordsAntibiotic resistanceAntibioticsClinical trialsDrugsInfectious diseasesInvestigational new drugMotivationMycobacteriaNew drug applicationsPathogens ePublished: 8 October 2019 Issue Published: 15 October 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Abstract Background This study compares the detection of respiratory pathogens between a multitest “Bundle” (MTB) and the Sputum FilmArray Pneumonia Panel (SFAPP). Methods Patients admitted from the ED with CAP were enrolled. The SFAPP probed for the presence of 18 bacterial species and 17 viral targets. The results were compared with pathogen detection with an MTB: (a) culture of sputum and blood; (b) urine antigens of S. pneumoniae and Legionella pneumophila; (c) Nasopharyngeal (NP) Respiratory FilmArray (NPRFA) panel which detects 17 viruses and 3 bacteria; and (d) nasal NAATs for S. pneumoniae and S. aureus. Two serum procalcitonin (PCT) levels helped separate bacterial colonization from invasion. Results Of 400 enrolled patients, 121 (30%) were non-evaluable due to a lack of a sputum specimen, 72 (18%) with a final diagnosis other than CAP, and other reasons in 21 (5%). Herein, the results of 186 (47%) evaluable patients with CAP and the Pneumonia Severity Index values of over 90 in 64.5%. The SFAPP detected viruses in 114/186 (61.3%) patients compared with 73/186 (39.2%) with the NPRFAP, p. The SFAPP detected bacterial pathogen(s) in 140/186 (75.3%) of patients vs. 117/183 (62.9%) with the MTB, pH. influenzae, M. catarrhalis, and S. agalactiae, p. A potential pathogenic bacteria and/or virus was detected in 176 of the 186 (95%) evaluable patients. Patients were classified as: virus detected (22); bacteria detected (57); bacteria and virus (97); CAP but no pathogen detected (10). The distribution of serum PCT levels by pathogen detected is shown in Figure 1. The dashed line is the 0.25 ng/mL “cut-off” to help separate colonization from invasion by bacteria. Antibiotic use was less in influenza patients with low PCT levels, p. In 22 patients with only virus detected and PCT. Conclusion The Sputum FilmArray Pneumonia Panel detected more bacteria and viral potential pathogens than the Multitest Bundle that included the Nasopharyngeal FilmArray Panel. The Sputum FilmArray Pneumonia Panel may allow removal of nasopharyngeal swabs and urine antigens from the MTB. Disclosures All authors: No reported disclosures.

Shifting to a nonprofit-driven model for development of antibiotics could encourage discovery and development of truly needed drugs that improve patient outcomes and permit more effective control over the postapproval use of antibiotics to prolong their effectiveness.

Belinda Ostrowsky, Ritu Banerjee, Robert A. Bonomo, Sara E. Cosgrove, Lisa Davidson, Shira Doron, David N. Gilbert, Amanda Jezek, John B. Lynch III, Edward J. Septimus, Javeed Siddiqui, and Nicole M. Iovine; for the Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and the Society for Healthcare Epidemiology of America Montefiore Medical Center, Albert Einstein Medical Center, Bronx, New York; Vanderbilt University Medical Center, Nashville, Tennessee; Research and Medical Services Veterans Affairs Medical Center, Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Case Western Reserve University, and Cleveland Geriatric Research Education and Clinical Center, Case Western Reserve University–Cleveland Veterans Affairs Medical Center, Center for Antimicrobial Resistance and Epidemiology, Ohio; Johns Hopkins University School of Medicine, Baltimore, Maryland; Carolinas Health Care System, Charlotte, North Carolina; Tufts Medical Center, Boston, Massachusetts; Providence-Portland Medical Center and Oregon Health Sciences University, Portland; Infectious Diseases Society of America, Arlington, Virginia; Harborview Medical Center, University of Washington, Seattle; HCA Healthcare, Nashville, Tennessee; Texas A&M College of Medicine, Houston; TeleMed2U, Roseville, California; and University of Florida College of Medicine, Gainesville

The combination of molecular pathogen diagnostics and the biomarker procalcitonin (PCT) are changing the use of antimicrobials in patients admitted to critical care units with severe community-acquired pneumonia, possible septic shock, or other clinical syndromes. An elevated serum PCT level is good supportive evidence of a bacterial pneumonia, whereas a low serum PCT level virtually eliminates an etiologic role for bacteria even if the culture for a potential bacterial pathogen is positive. Serum PCT levels can be increased in any shocklike state; a low PCT level eliminates invasive bacterial infection as an etiology in more than 90% of patients.

Hospitals will soon require antibiotic stewardship programs. Infectious diseases specialists must craft business plans to engage hospital leadership to fund such programs. In this article, we review key cost and revenue elements that should be covered in such plans.Society is placing increasing emphasis on the importance of antimicrobial stewardship programs (ASPs). New regulatory standards require hospitals to implement ASPs. Infectious Diseases (ID) specialists will need to help design and implement such programs at hospitals. A critical component of establishing such programs is submitting a business plan to hospital leadership justifying the cost and structure of the ASP and explaining what benefits the hospital will gain in return. In this article, we explore typical elements of such business plans and describe how hospital leadership may evaluate and determine the value of such plans. Understanding hospital costs and revenue models is critical to creating a viable and realistic business plan to support ASPs.

The etiology of community-acquired pneumonia (CAP) is determined in less than half of the patients based on cultures of sputum and blood plus testing urine for the antigens of Streptococcus pneumoniae and Legionella pneumophila. This study added nasal polymerase chain reaction (PCR) probes for S. pneumoniae, Staphylococcus aureus, and respiratory viruses. Serum procalcitonin (PCT) levels were measured. Pathogens were identified in 78% of the patients. For detection of viruses, patients were randomized to either a 5-virus laboratory-generated PCR bundle or the 17-virus FilmArray PCR platform. The FilmArray PCR platform detected more viruses than the laboratory-generated bundle and did so in less than 2 hours. There were fewer days of antibiotic therapy, P = 0.003, in CAP patients with viral infections and a low serum PCT levels.