scholarly journals C-reactive protein-guided antibiotic prescribing for COPD exacerbations: a qualitative evaluation

2020 ◽  
Vol 70 (696) ◽  
pp. e505-e513
Author(s):  
Rhiannon Phillips ◽  
Helen Stanton ◽  
Amina Singh-Mehta ◽  
David Gillespie ◽  
Janine Bates ◽  
...  
Keyword(s):  
Primary Care ◽  
Controlled Trial ◽  
Care Staff ◽  
Chronic Obstructive ◽  
Routine Practice ◽  
Antibiotic Prescribing ◽  
C Reactive Protein ◽  
Potential Barriers ◽  
Reactive Protein ◽  
Patient Reported

BackgroundAntibiotics are prescribed to >70% of patients presenting in primary care with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The PACE randomised controlled trial found that a C-reactive protein point-of-care test (CRP-POCT) management strategy for AECOPD in primary care resulted in a 20% reduction in patient-reported antibiotic consumption over 4 weeks.AimTo understand perceptions of the value of CRP-POCT for guiding antibiotic prescribing for AECOPD; explore possible mechanisms, mediators, and pathways to effects; and identify potential barriers and facilitators to implementation from the perspectives of patients and clinicians.Design and settingQualitative process evaluation in UK general practices.MethodSemi-structured telephone interviews with 20 patients presenting with an AECOPD and 20 primary care staff, purposively sampled from the PACE study. Interviews were audio-recorded, transcribed, and analysed using framework analysis.ResultsPatients and clinicians felt that CRP-POCT was useful in guiding clinicians’ antibiotic prescribing decisions for AECOPD, and were positive about introduction of the test in routine care. The CRP-POCT enhanced clinician confidence in antibiotic prescribing decisions, reduced decisional ambiguity, and facilitated communication with patients. Some clinicians thought the CRP-POCT should be routinely used in consultations for AECOPD; others favoured use only when there was decisional uncertainty. CRP-POCT cartridge preparation time and cost were potential barriers to implementation.ConclusionCRP-POCT-guided antibiotic prescribing for AECOPD had high acceptability, but commissioning arrangements and further simplification of the CRP-POCT need attention to facilitate implementation in routine practice.

scholarly journals Implementation of C-reactive protein point of care testing to improve antibiotic targeting in respiratory illness in Vietnamese primary care (ICAT): a study protocol for a cluster randomised controlled trial

BMJ Open ◽  
2020 ◽  
Vol 10 (12) ◽  
pp. e040977
Author(s):  
Nga Thi Thuy Do ◽  
Rachel Claire Greer ◽  
Yoel Lubell ◽  
Sabine Dittrich ◽  
Maida Vandendorpe ◽  
...  
Keyword(s):  
Primary Care ◽  
Antibiotic Prescription ◽  
Point Of Care ◽  
Controlled Trial ◽  
Cluster Randomised Controlled Trial ◽  
Antibiotic Use ◽  
Routine Care ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Randomised Controlled

IntroductionC-reactive protein (CRP), a biomarker of infection, has been used widely in high-income settings to guide antibiotic treatment in patients presenting with respiratory illnesses in primary care. Recent trials in low- and middle-income countries showed that CRP testing could safely reduce antibiotic use in patients with non-severe acute respiratory infections (ARIs) and fever in primary care. The studies, however, were conducted in a research-oriented context, with research staff closely monitoring healthcare behaviour thus potentially influencing healthcare workers’ prescribing practices. For policy-makers to consider wide-scale roll-out, a pragmatic implementation study of the impact of CRP point of care (POC) testing in routine care is needed.Methods and analysisA pragmatic, cluster-randomised controlled trial, with two study arms, consisting of 24 commune health centres (CHC) in the intervention arm (provision of CRP tests with additional healthcare worker guidance) and 24 facilities acting as controls (routine care). Comparison between the treatment arms will be through logistic regression, with the treatment assignment as a fixed effect, and the CHC as a random effect. With 48 clusters, an average of 10 consultations per facility per week will result in approximately 520 over 1 year, and 24 960 in total (12 480 per arm). We will be able to detect a reduction of 12% to 23% or more in immediate antibiotic prescription as a result of the CRP POC intervention. The primary endpoint is the proportion of patient consultations for ARI resulting in immediate antibiotic prescription. Secondary endpoints include the proportion of all patients receiving an antibiotic prescription regardless of ARI diagnosis, frequency of re-consultation, subsequent antibiotic use when antibiotics are not prescribed, referral and hospitalisation.Ethics and disseminationThe study protocol was approved by the Oxford University Tropical Research Ethics Committee (OxTREC, Reference: 53–18), and the ethical committee of the National Hospital for Tropical Diseases in Vietnam (Reference:07/HDDD-NDTW/2019). Results from this study will be disseminated via meetings with stakeholders, conferences and publications in peer-reviewed journals. Authorship and reporting of this work will follow international guidelines.Trial registration detailsNCT03855215; Pre-results.

scholarly journals Cost-Effectiveness Analysis of the Use of Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing in Primary Care

Antibiotics ◽  
2018 ◽  
Vol 7 (4) ◽  
pp. 106 ◽  
Author(s):  
Emily Holmes ◽  
Sharman Harris ◽  
Alison Hughes ◽  
Noel Craine ◽  
Dyfrig Hughes
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
Respiratory Tract ◽  
Clinical Guidelines ◽  
Antibiotic Prescription ◽  
Point Of Care ◽  
Cost Effective ◽  
Routine Practice ◽  
C Reactive Protein ◽  
Reactive Protein

More appropriate and measured use of antibiotics may be achieved using point-of-care (POC) C-reactive protein (CRP) testing, but there is limited evidence of cost-effectiveness in routine practice. A decision analytic model was developed to estimate the cost-effectiveness of testing, compared with standard care, in adults presenting in primary care with symptoms of acute respiratory tract infection (ARTI). Analyses considered (1) pragmatic use of testing, reflective of routine clinical practice, and (2) testing according to clinical guidelines. Threshold and scenario analysis were performed to identify cost-effective scenarios. In patients with symptoms of ARTI and based on routine practice, the incremental cost-effectiveness ratios of CRP testing were £19,705 per quality-adjusted-life-year (QALY) gained and £16.07 per antibiotic prescription avoided. Following clinical guideline, CRP testing in patients with lower respiratory tract infections (LRTIs) cost £4390 per QALY gained and £9.31 per antibiotic prescription avoided. At a threshold of £20,000 per QALY, the probabilities of POC CRP testing being cost-effective were 0.49 (ARTI) and 0.84 (LRTI). POC CRP testing as implemented in routine practice is appreciably less cost-effective than when adhering to clinical guidelines. The implications for antibiotic resistance and Clostridium difficile infection warrant further investigation.

scholarly journals Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

Antibiotics ◽  
2020 ◽  
Vol 9 (9) ◽  
pp. 610
Author(s):  
Nahara Anani Martínez-González ◽  
Ellen Keizer ◽  
Andreas Plate ◽  
Samuel Coenen ◽  
Fabio Valeri ◽  
...  
Keyword(s):  
Primary Care ◽  
Respiratory Tract ◽  
Usual Care ◽  
Respiratory Tract Infections ◽  
Point Of Care ◽  
Antibiotic Prescribing ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Meta Analyses ◽  
Tract Infections

C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

scholarly journals C-reactive protein testing reduces antibiotics prescription in a community setting

2019 ◽  
Vol 69 (suppl 1) ◽  
pp. bjgp19X703313
Author(s):  
Abdus Burahee ◽  
Owen Hibberd ◽  
Aneja Malladi
Keyword(s):  
Primary Care ◽  
Sore Throat ◽  
Clinical Decision Making ◽  
Respiratory Illness ◽  
Antibiotic Prescribing ◽  
C Reactive Protein ◽  
Health Seeking ◽  
Retrospective Case ◽  
Reactive Protein ◽  
The Impact

BackgroundOveruse of antimicrobials and the threats posed by resistance are concerning. Most patients in primary care with respiratory tract symptoms are prescribed antibiotics, amounting between 80–90% of all prescriptions. The National Institute for Health and Care Excellence (NICE) recommends point-of-care (POC) testing of C-reactive protein (CRP) where there is uncertainty about prescribing antibiotics. Studies evaluating the use of POC CRP to reduce antibiotic prescribing for self-limiting respiratory illness in primary care have demonstrated heterogeneity in their results.AimTo evaluate the impact of POC CRP testing on antibiotic prescribing.MethodA retrospective case analysis was undertaken at a GP practice. Alere Afinion AS100 was used for POC CRP testing. Data were collected on patients presenting with cough or sore throat who had POC CRP testing used in their clinical decision making. Eighty-four cases were selected for inclusion. NICE clinical guideline CG191 was used as a standard comparator for antibiotic prescribing and patients were followed up over a 2-month period.ResultsPatients presented with cough (n = 56) and sore throat (n = 28). At initial presentation 23/84 (27.4%) of patients were prescribed antibiotics. Over the 2-month follow-up period 15/84 (17.8%) of patients had at least one further consultation related to their initial respiratory complaint with 6/84 (7.1%) being prescribed antibiotics. The overall effect was a reduction of antibiotic prescriptions by 65.5%.ConclusionThe use of POC CRP testing helped GPs reduce the rate of antibiotic prescription and improve antimicrobial stewardship by being an addition to their diagnostic armoury. It has also shown potential role in patient reassurance and modifying health seeking behaviour.

C-reactive protein point-of-care testing in acutely ill children: a mixed methods study in primary care

2016 ◽  
Vol 101 (4) ◽  
pp. 382-386 ◽  
Author(s):  
Ann Van den Bruel ◽  
Caroline Jones ◽  
Matthew Thompson ◽  
David Mant
Keyword(s):  
Primary Care ◽  
Mixed Methods ◽  
Qualitative Study ◽  
Point Of Care ◽  
Mixed Methods Study ◽  
Contributory Factor ◽  
Antibiotic Prescribing ◽  
Point Of Care Testing ◽  
C Reactive Protein ◽  
Reactive Protein

BackgroundPoint-of-care C-reactive protein (CRP) testing of adults with acute respiratory infection in primary care reduces antibiotic prescribing by 22%. The acceptability and impact of CRP testing in children is unknownObjectiveTo determine the acceptability and impact of CRP testing in acutely ill children.DesignMixed methods study comprising an observational cohort with a nested randomised controlled trial and embedded qualitative study.Subjects and settingChildren presenting with an acute illness to general practice out-of-hours services; children with a temperature ≥38°C were randomised in the nested trial; parents and clinical staff were invited to the qualitative study.Main outcomesInformed consent rates; parental and staff views on testing.ResultsConsent to involvement in the study was obtained for 200/297 children (67.3%, 95% CI 61.7% to 72.6%); the finger-prick test might have been a contributory factor for 63 of the 97 children declining participation but it was cited as a definite factor in only 10 cases. None of the parents or staff raised concerns about the acceptability of testing, describing the pain caused as minor and transient. General practitioner views on the utility of the CRP test were inconsistent.ConclusionsCRP point-of-care testing in children is feasible in primary care and is likely to be acceptable. However, it will not reduce antibiotic prescribing and hospital referrals until general practitioners accept its diagnostic value in children.Trial registration numberISRCTN 69736109.

scholarly journals Effects of primary care C-reactive protein point-of-care testing on antibiotic prescribing by general practice staff: pragmatic randomised controlled trial, England, 2016 and 2017

2020 ◽  
Vol 25 (44) ◽  
Author(s):  
Charlotte Victoria Eley ◽  
Anita Sharma ◽  
Hazel Lee ◽  
Andre Charlett ◽  
Rebecca Owens ◽  
...  
Keyword(s):  
Point Of Care ◽  
Controlled Trial ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
C Reactive Protein ◽  
Acute Cough ◽  
Reactive Protein ◽  
General Practices ◽  
Randomised Controlled ◽  
Pragmatic Randomised Controlled Trial

Background C-reactive protein (CRP) testing can be used as a point-of-care test (POCT) to guide antibiotic use for acute cough. Aim We wanted to determine feasibility and effect of introducing CRP POCT in general practices in an area with high antibiotic prescribing for patients with acute cough and to evaluate patients’ views of the test. Methods We used a McNulty–Zelen cluster pragmatic randomised controlled trial design in general practices in Northern England. Eight intervention practices accepted CRP testing and eight control practices maintained usual practice. Data collection included process evaluation, patient questionnaires, practice audit and antibiotic prescribing data. Results Eight practices with over 47,000 patient population undertook 268 CRP tests over 6 months: 78% of patients had a CRP < 20 mg/L, 20% CRP 20–100 mg/L and 2% CRP > 100 mg/L, where 90%, 22% and 100%, respectively, followed National Institute for Health and Care Excellence (NICE) antibiotic prescribing guidance. Patients reported that CRP testing was comfortable (88%), convenient (84%), useful (92%) and explained well (85%). Patients believed CRP POCT aided clinical diagnosis, provided quick results and reduced unnecessary antibiotic use. Intervention practices had an estimated 21% reduction (95% confidence interval: 0.46–1.35) in the odds of prescribing for cough compared with the controls, a non-significant but clinically relevant reduction. Conclusions In routine general practice, CRP POCT use was variable. Non-significant reductions in antibiotic prescribing may reflect small sample size due to non-use of tests. While CRP POCT may be useful, primary care staff need clearer CRP guidance and action planning according to NICE guidance.

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