Impact of Syndromic Molecular Diagnostics on Antimicrobial Adequacy and Time to Therapy in Critically Ill Patients with Pneumonia: A Systematic Review and Meta-Analysis of Randomized Trials
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Background Pneumonia is a leading cause of ICU admission and mortality, requiring prompt and adequate antimicrobial therapy to improve outcomes. Conventional cultures are slow and often insensitive, delaying targeted treatment. Syndromic PCR panels offer rapid identification of pathogens and resistance genes directly from respiratory samples, potentially improving early antibiotic optimization. However, the true clinical benefit of these diagnostics in critically ill patients remains uncertain Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PCR-based molecular diagnostics with standard culture techniques in adult ICU patients with severe community-acquired, hospital-acquired, or ventilator-associated pneumonia. Literature searches were performed in PubMed, Embase, and Cochrane CENTRAL from inception to April 1, 2025. The primary outcomes were adequacy of initial antimicrobial therapy, time to effective antibiotic therapy, and in-hospital mortality. Data were synthesized using random-effects models. Results We included four RCTs comprising 2,031 patients. Syndromic PCR testing significantly increased the likelihood of receiving adequate initial antimicrobial therapy (OR 5.23; 95% CI: 2.27–12.05; p = 0.0001; I² = 83%) and reduced time to directed antibiotic therapy (mean difference − 41.07 hours; 95% CI: − 72.78 to − 9.35; p = 0.01; I² = 100%). No significant difference in in-hospital mortality was observed (RR 1.09; 95% CI: 0.92–1.28; p = 0.32; I² = 0%). Conclusions Syndromic PCR diagnostics improve antibiotic adequacy and accelerate the initiation of targeted therapy in critically ill pneumonia patients, supporting their integration into ICU-based antimicrobial stewardship strategies. Trial registration: PROSPERO CRD420251006301.