Point-of-care C-reactive Protein Testing Research Articles

C-reactive protein point-of-care testing and complementary strategies to improve antibiotic stewardship in children with acute respiratory infections in primary care.

This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered.

Preparing of Point-of-Care Reagents for Risk Assessment in the Elderly at Home by a Home-Visit Nurse and Verification of Their Analytical Accuracy.

With the rising number of older adults residing at home, there is a growing need for risk assessment and patient management in home nursing. This study aims to develop point-of-care test (POCT) reagents that can aid in risk assessment and home care, especially in settings with limited resources. Our focus was on creating a C-reactive protein (CRP) POCT, which can accurately diagnose clinically significant judgment values in home nursing. Additionally, we assessed the utility of the HemoCue WBC DIFF system in providing differential counts of white blood cells (WBC). These performances were compared with a laboratory test using blood samples from patients with pneumonia. The CRP POCT showed a comparable result to that of a laboratory method, with an average kappa index of 0.883. The leukocyte count showed good agreement with the reference method. While the correlation coefficients for both neutrophil and lymphocyte counts were deemed acceptable, it was observed that the measured values tended to be smaller in cases where the cell count was higher. This proportional error indicates a weak correlation with the neutrophil-to-lymphocyte ratio. CRP POCT and WBC counts provided reliable and accurate judgments. These tools may benefit risk management for older adults at home, patients with dementia who cannot communicate, and those living in depopulated areas.

Validation Study of Novel Point-of-Care Tests for Infliximab, Adalimumab and C-Reactive Protein in Capillary Blood and Calprotectin in Faeces in an Ambulatory Inflammatory Bowel Disease Care Setting.

Background and aims: Point-of-care tests (POCT) allow instant measurement of inflammatory markers and drug concentrations. Here, we studied agreement between a novel POCT device and reference methods of measuring infliximab (IFX) and adalimumab (ADL) serum concentrations and C-reactive protein (CRP) and faecal calprotectin (FCP) concentrations of patients with inflammatory bowel disease (IBD). Methods: In this single-centre validation study, IBD patients were recruited in which IFX, ADL, CRP and/or FCP tests were required. IFX, ADL and CRP POCT were performed on capillary whole blood (CWB), obtained via finger prick. Additionally, IFX POCT was performed on serum samples. FCP POCT was performed on stool samples. Agreement between POCT and reference methods was tested using Passing-Bablok regression, intra-class correlation coefficients (ICC) and Bland-Altman plots. Results: In total, 285 patients participated. Passing-Bablok regression identified differences between the reference method and IFX CWB POCT (intercept = 1.56), IFX serum POCT (intercept = 0.71, slope = 1.10) and ADL CWB POCT (intercept = 1.44). There were also differences in the Passing-Bablok regressions of CRP (intercept = 0.81, slope = 0.78) and FCP (intercept = 51 and slope = 0.46). Bland-Altman plots demonstrated that IFX and ADL concentrations were slightly higher with the POCT and CRP and FCP were slightly lower with POCT. The ICC demonstrated almost perfect agreement with IFX CWB POCT (ICC = 0.85), IFX serum POCT (ICC = 0.96), ADL CWB POCT (ICC = 0.82) and CRP CWB POCT (ICC = 0.91) and moderate agreement with FCP POCT (ICC = 0.55). Conclusions: IFX and ADL results were slightly higher with this novel rapid and user-friendly POCT, whereas CRP and FCP results were slightly lower compared to the reference methods.

C reactive protein-guided prescription of antibiotics for children under 12 years with respiratory symptoms in Kyrgyzstan: protocol for a randomised controlled clinical trial with 14 days follow-up

IntroductionWhile lower respiratory tract infections are the main cause of death for children under 5 globally, only a small proportion of children with respiratory tract infections need antibiotics. Overuse of...

Development over time in point-of-care test use in Danish daytime and out-of-hours general practice: a register-based study

Objective To describe the development over time of the use of C-reactive protein (CRP) and rapid streptococcal detection test (RADT) point-of-care tests (POCT) in Danish general practice and to explore associations between patient characteristics and POCT use (i.e. CRP and RADT). Design and settings A register-based study including all general practice clinic consultations in daytime and out-of-hours (OOH) settings in Denmark between 2003 and 2018. Subjects All citizens who had at least one clinic consultation in daytime or OOH general practice within the study period. Main outcome measures We estimated the total and relative use of CRP and RADT POCTs and described the development over time. Crude and adjusted proportion ratios (PRs) were calculated to explore associations between patient characteristics and POCT use. Results Overall, the relative use of CRP POCTs increased. At OOH, a steep increase was noticed around 2012. The relative use of RADT decreased. Patient age 40–59 years and existing comorbidity were significantly associated with a higher use of CRP testing in both settings. A significantly lower use of CRP testing was found for patients with higher educational level. We found a significantly higher use of RADT testing for patients aged 0–19 years and with higher household educational level, whereas comorbidity was associated with a lower use of RADT testing. Conclusion The use of CRP POCT increased over time, whereas the use of RADT POCT decreased. Perhaps the success of implementing CRP as a tool for reducing antibiotic use has reached it limit. Future studies should focus on how and when POCT are used most optimal. Key points CRP POC tests and RADT POCTs are frequently used diagnostic tools in general practice, both in daytime and in the out-of-hours setting. There was an increased use of CRP POCTs, particularly in out-of-hours general practice, whereas the use of RADT POCTs declined between 2003 and 2018. CRP POCTs were associated with age of 40–59 years and co-morbidity, while the use of RADT was mostly associated with younger age.

Implementing antibiotic stewardship in high-prescribing English general practices: a mixed-methods study.

Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. The authors co-developed an implementation intervention to improve use of three AMS strategies: enhanced communication strategies, delayed prescriptions, and point-of-care C-reactive protein tests (POC-CRPTs). To investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing. Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an 'antibiotic champion'. Routinely collected prescribing data were compared between the intervention and the control practices. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention. There was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual champions' preconceptions of strategies and the opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPTs; one practice chose all three. POC-CRPTs was used more when allocated to one person. Clinicians need detailed information on exactly how to adopt AMS strategies. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.

Introducing the C-reactive protein point-of-care test: A conversation analytic study of primary care consultations for respiratory tract infection

The C-reactive protein point-of-care test (CRP-POCT) can help distinguish between viral and bacterial infection and has been promoted as a strategy to improve antimicrobial stewardship. The test is widely used in Sweden. National guidelines advocate conservative use in primary care consultations with patients presenting with symptoms of respiratory tract infection (RTI). Previous research suggests low adherence to guidelines. We provide new insights into the communication surrounding the CRP-POCT by documenting how the decision to administer the test is interactionally motivated and organized in Swedish primary care. The data consists of video-recordings of RTI-consultations. A CRP-POCT was performed in nearly two thirds of the consultations and our study is focused on a subset where the test is ordered by a medical doctor. We find that doctors order the test during the transition from or after physical examination, a practice that aligns with national guidelines. Guidelines indicate that pathological findings from physical examination are warrants for ordering the test but we only found one example where this was communicated to the patient. A more prevalent pattern was that doctors ordered the CRP-POCT even though the outcome of the physical examination was assessed as normal. Our analyses of these show that doctors can provide the rationale for ordering the test in subtle ways and that failure to provide a rationale is treated as a noticeable absence. We also find that the CRP-POCT can be used to reconcile the contrast between the normal physical examination and the patient's problem presentation. Doctors can also order the test in ways that position the CRP-POCT as criterial for antibiotic prescription. Consultations where the patients described the symptoms as particularly severe and/or persistent were more likely to engender elaborate accounts than consultations where patients presented their symptoms as less problematic.

EE297 Systematic Review of Economic Evaluations of C-Reactive Protein Point-of-Care Testing in Primary Care: Do We Need to Do Better?

Many patients are prescribed antibiotics despite most infections being viral. Overprescribing of antibiotics results in antimicrobial resistance (AMR). C-reactive protein (CRP) point-of-care tests (POCT) reduce diagnostic uncertainty. The studies that evaluated the cost-effectiveness of CRP POCT for patients with respiratory tract infections (RTI) reported inconsistent findings. To inform the uptake of POCT, it is crucial to understand why such variability exists.

Economic evaluation of antimicrobial stewardship in primary care: a systematic review and quality assessment

BackgroundPrimary care accounts for 80%–90% of antimicrobial prescriptions, making this setting an important focus for antimicrobial stewardship (AMS) interventions.ObjectivesTo collate the findings and critically appraise the qualities of economic evaluation studies of AMS or related interventions aimed at reducing inappropriate antimicrobial prescribing in primary care.MethodsA systematic review of economic evaluations of interventions aimed at reducing inappropriate antimicrobial prescribing in primary care was performed. Published literature were retrieved through a search of Medline, Embase, EconLit and Web of Science databases for the period 2010 to 2020. The quality of the studies was assessed using the Consensus on Health Economic Criteria checklist and Good Practice Guidelines for Decision-Analytic Modelling in Health Technology Assessment.ResultsOf the 2722 records identified, 12 studies were included in the review (8 trial-based and 4 modelled evaluations). The most common AMS interventions were communication skills training for health professionals and C-reactive protein point-of-care testing (CRP-POCT). Types of economic evaluations included in the review were cost-effectiveness (7 studies), cost-utility (1), cost-benefit (2), cost-effectiveness and cost-utility (1) and cost analysis (1). While six of the studies found AMS interventions to be cost-effective, the other six reported them as not cost-effective or inconclusive. The quality of the studies ranged from good to low.ConclusionsThere were significant variations in cost-effectiveness of AMS interventions across studies and depending on the inclusion of cost components such as the cost of antimicrobial resistance. However, communication skills training and CRP-POCT were frequently cost-effective or cost-beneficial for reducing inappropriate antimicrobial prescribing.

O01 Nuances of implementing antibiotic stewardship in high-prescribing English general practices: an implementation study

BackgroundTrials have identified several antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England and evidence is lacking around how to support high-prescribing general practices to implement AMS. We co-developed a customizable implementation intervention to improve adoption and use of three AMS strategies; enhanced communication strategies with/without patient leaflets, delayed prescriptions, and point-of-care C-reactive protein testing (POC-CRPT). This study aimed to investigate the use of the implementation intervention in high-prescribing practices and its effect on antibiotic prescribing.MethodsNine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via the ‘Antibiotic Optimisation’ website with practices required to identify an in-practice ‘Antibiotic Champion’. In a mixed-methods evaluation, we compared routinely collected prescribing data between 9 intervention and 45 matched control practices using a difference in differences analysis. Intervention material use was assessed through website monitoring and practice requests for supplies. Surveys and interviews were conducted with professionals at baseline and follow-up timepoints to capture experiences of using the intervention.ResultsThere was no evidence that the intervention affected antibiotic prescribing. Engagement with intervention materials differed substantially between practices and depended on the individual Antibiotic Champion's preconceptions regarding the AMS strategies and opportunity to do the implementation tasks. Champions in five practices initiated changes to encourage use of at least one of the three AMS strategies, mostly POC-CRPT and patient leaflets. One Champion used the website resources to drive discussions about implementation of all three strategies in their practice. Elsewhere, lack of website engagement meant clinicians did not recognize novelty in the communication and delayed prescription content. POC-CRPT was used most often when equipment was allocated to one person in a practice.ConclusionsAMS strategies are complex interventions and require clinicians to have detailed knowledge on how to adopt them in practice if they are to reduce antibiotic prescribing. Successful adoption may be achieved by allocating one or two persons to use an AMS strategy rather than all clinicians. Although effective in trials, remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.

Cost-effectiveness of point-of-care C-Reactive Protein test compared to current clinical practice as an intervention to improve antibiotic prescription in malaria-negative patients in Afghanistan.

Antimicrobial resistance (AMR) is a global health problem requiring a reduction in inappropriate antibiotic prescribing. Point-of-Care C-Reactive Protein (POCCRP) tests could distinguish between bacterial and non-bacterial causes of fever in malaria-negative patients and thus reduce inappropriate antibiotic prescribing. However, the cost-effectiveness of POCCRP testing is unclear in low-income settings. A decision tree model was used to estimate cost-effectiveness of POCCRP versus current clinical practice at primary healthcare facilities in Afghanistan. Data were analysed from healthcare delivery and societal perspectives. Costs were reported in 2019 USD. Effectiveness was measured as correctly treated febrile malaria-negative patient. Cost, effectiveness and diagnostic accuracy parameters were obtained from primary data from a cost-effectiveness study on malaria rapid diagnostic tests in Afghanistan and supplemented with POCCRP-specific data sourced from the literature. Incremental cost-effectiveness ratios (ICERs) reported the additional cost per additional correctly treated febrile malaria-negative patient over a 28-day time horizon. Univariate and probabilistic sensitivity analyses examined the impact of uncertainty of parameter inputs. Scenario analysis included economic cost of AMR per antibiotic prescription. The model predicts that POCCRP intervention would result in 137 fewer antibiotic prescriptions (6%) with a 12% reduction (279 prescriptions) in inappropriate prescriptions compared to current clinical practice. ICERs were $14.33 (healthcare delivery), $11.40 (societal), and $9.78 (scenario analysis) per additional correctly treated case. POCCRP tests could improve antibiotic prescribing among malaria-negative patients in Afghanistan. Cost-effectiveness depends in part on willingness to pay for reductions in inappropriate antibiotic prescribing that will only have modest impact on immediate clinical outcomes but may have long-term benefits in reducing overuse of antibiotics. A reduction in the overuse of antibiotics is needed and POCCRP tests may add to other interventions in achieving this aim. Assessment of willingness to pay among policy makers and donors and undertaking operational trials will help determine cost-effectiveness and assist decision making.

A cost-effectiveness and budget impact analysis of C-reactive protein point-of-care testing to guide antibiotic prescribing for acute respiratory tract infections in primary care settings in Ireland: a decision-analytic model.

Approximately 60% of antibiotics issued in primary care are for acute respiratory tract infections (RTIs), which are largely self-limiting and do not require antibiotics. Point-of-care testing (POCT) devices that measure C-reactive protein (CRP)-a biomarker for infection-can be used to guide prescribing decisions. We evaluated the cost-effectiveness and budget impact of a national CRP POCT program to guide antibiotic prescribing for acute RTIs in primary care in Ireland. We compared CRP POCT with and without enhanced communication skills training of general practitioners against usual care. A probabilistic decision tree was used to investigate cost-effectiveness from the perspective of the healthcare system. The model considered outcomes for the Irish population over a 5-year time horizon. Inputs were synthesized from published studies. Cost-effectiveness was estimated using an incremental cost per prescription avoided. CRP POCT with and without communication training were more costly but more effective than usual care over 5 years. CRP POCT alone was dominated, while the combined intervention had a cost per prescription avoided of €111 (95% CI: €45-243) versus usual care. The budget impact was costly over 5 years, but potential budget savings were available depending on the implementation scenario. The findings were largely robust to sensitivity analyses. CRP POCT reduces antibiotic prescribing, but increases healthcare costs. The most cost-effective program of CRP POCT includes enhanced communication skills training. Further research on the impact of CRP POCT beyond 5 years is warranted, as well as the potential impact on antimicrobial resistance.

Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice

BackgroundTrials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care.MethodsWe drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified ‘guiding principles’ with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals.ResultsFocus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an ‘implementation support’ website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts).ConclusionsWe used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance.

Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices

BackgroundTrials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use.MethodsThis was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically.ResultsNine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience – participants viewed the strategies as having limited value as ‘clinical tools’, perceiving them as useful only in ‘rare’ instances of clinical uncertainty and/or for those less experienced. Strategies as ‘social tools’ – participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities – participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context – various other situational and practical issues were raised with implementing the strategies.ConclusionsHigh-prescribing practices do not view DPs and POC-CRPT as sufficiently useful ‘clinical tools’ in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as ‘social tools’ to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.

Point-of-care C-reactive protein testing to support the management of respiratory tract infections in community pharmacy: A feasibility study.

Point-of-care (POC) C-reactive protein (CRP) testing is employed in European primary care settings to differentiate viral from bacterial respiratory tract infections (RTIs) the latter, requiring referral for antibiotics. This service has yet to be trialled in Australian community pharmacy to support over-the-counter RTI management. To evaluate the feasibility, based on clinical and operational outcomes, of POC CRP testing to support Western Australian community pharmacists' management of RTIs. Patients with RTI signs and symptoms were recruited from June-August 2019at 5 community pharmacies. Trained pharmacists made recommendations based on participants' POC CRP levels and routine clinical assessment. Participants completed questionnaires and telephone follow-ups on Days 3 (by pharmacists) and 5 (by researchers) post-testing. Service provision and uptake were assessed in 3 separate weekly tally sheets. Clinical outcomes: CRP levels among the 131 participants recruited were: < 5mg/L (bacterial infection unlikely; n=60; 45.8%); 5-19mg/L (bacterial infection possible if suggestive routine assessment; n=52; 39.7%) and 20-100mg/L (bacterial infection likely if suggestive routine assessment; n=19; 14.5%). Pharmacists' management included over-the-counter medicines (131, 100%), self-care advice (125, 95.4%) and immediate general practitioner (GP) referral (15, 11.5%). Sixty-five percent (76/117) of participants had recovered by Day 5. Operational outcomes: The services was provided in 21.2% of eligible RTI presentations, representing a service uptake rate of 28.1%. Post-CRP testing, 50.9% (58/114) of participants had changed perceptions regarding their need for antibiotics, with 14.3% (16/112) subsequently intending to seek a GP prescription. Consumer satisfaction was high (100%) and most participants (93.4%, 123/131) would utilise the service again. POC CRP testing was a feasible and well-accepted strategy to facilitate community pharmacy as a triage point for RTI. Consumer confidence in the pharmacists' advice, supported by CRP testing, potentially reduced unnecessary GP visits and antibiotic prescribing.

Usefulness of C-Reactive Protein and Other Host BioMarker Point-of-Care Tests in the Assessment of Non-Malarial Acute Febrile Illnesses: A Systematic Review with Meta-Analysis.

In low- and middle-income countries, in resource-limited settings, the implementation of diagnostic tools discriminating bacterial from nonbacterial fever is a matter of primary concern. The introduction of malaria rapid diagnostic tests highlighted the need for point-of-care tests (POCTs) supporting clinical decision-making for non-malarial febrile illnesses. The purpose of this work was to review the use of host biomarker POCTs for the assessment of acute non-malarial fever in resource-constraint settings. Specific objectives were as follows: 1) to estimate the accuracy of such tests in differentiating fever of bacterial from nonbacterial origin and 2) to assess the impact of host biomarkers on antibiotic prescription and clinical outcome. We conducted a systematic review searching PubMed, Embase, the Cochrane Library, and Bireme. The protocol was registered with PROSPERO (n CRD42019141735). Data on the accuracy of C-reactive protein (CRP) for the detection of bacterial infections were meta-analyzed using the hierarchical summary receiver operating characteristic model, obtaining a summary ROC (SROC). We identified 2,192 articles, eight of which were included in the review. Among the different biomarkers evaluated, CRP was the one most frequently studied. The SROC presented an area under the curve = 0.77 (CI: 0.73-0.81), which indicates good accuracy to distinguish bacterial from nonbacterial infections. However, the optimal cutoff of CRP could not be assessed, and we found insufficient evidence about its impact on antibiotic prescription and clinical outcome. The role of CRP and other host biomarker POCTs for the assessment of acute non-malarial febrile illnesses in resource-constraint settings deserves further studies.

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

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.

C-reactive protein point-of-care testing for safely reducing antibiotics for acute exacerbations of chronic obstructive pulmonary disease: the PACE RCT.

Most patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed antibiotics, but these may not be beneficial, and they can cause side effects and increase the risk of subsequent resistant infections. Point-of-care tests (POCTs) could safely reduce inappropriate antibiotic prescribing and antimicrobial resistance. To determine whether or not the use of a C-reactive protein (CRP) POCT to guide prescribing decisions for AECOPD reduces antibiotic consumption without having a negative impact on chronic obstructive pulmonary disease (COPD) health status and is cost-effective. A multicentre, parallel-arm, randomised controlled open trial with an embedded process, and a health economic evaluation. General practices in Wales and England. A UK NHS perspective was used for the economic analysis. Adults (aged ≥ 40 years) with a primary care diagnosis of COPD, presenting with an AECOPD (with at least one of increased dyspnoea, increased sputum volume and increased sputum purulence) of between 24 hours' and 21 days' duration. CRP POCTs to guide antibiotic prescribing decisions for AECOPD, compared with usual care (no CRP POCT), using remote online randomisation. Patient-reported antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status as measured with the Clinical COPD Questionnaire (CCQ) at 2 weeks. For the economic evaluation, patient-reported resource use and the EuroQol-5 Dimensions were included. In total, 653 participants were randomised from 86 general practices. Three withdrew consent and one was randomised in error, leaving 324 participants in the usual-care arm and 325 participants in the CRP POCT arm. Antibiotics were consumed for AECOPD by 212 out of 274 participants (77.4%) and 150 out of 263 participants (57.0%) in the usual-care and CRP POCT arm, respectively [adjusted odds ratio 0.31, 95% confidence interval (CI) 0.20 to 0.47]. The CCQ analysis comprised 282 and 281 participants in the usual-care and CRP POCT arms, respectively, and the adjusted mean CCQ score difference at 2 weeks was 0.19 points (two-sided 90% CI -0.33 to -0.05 points). The upper limit of the CI did not contain the prespecified non-inferiority margin of 0.3. The total cost from a NHS perspective at 4 weeks was £17.59 per patient higher in the CRP POCT arm (95% CI -£34.80 to £69.98; p = 0.408). The mean incremental cost-effectiveness ratios were £222 per 1% reduction in antibiotic consumption compared with usual care at 4 weeks and £15,251 per quality-adjusted life-year gained at 6 months with no significant changes in sensitivity analyses. Patients and clinicians were generally supportive of including CRP POCT in the assessment of AECOPD. A CRP POCT diagnostic strategy achieved meaningful reductions in patient-reported antibiotic consumption without impairing COPD health status or increasing costs. There were no associated harms and both patients and clinicians valued the diagnostic strategy. Implementation studies that also build on our qualitative findings could help determine the effect of this intervention over the longer term. Current Controlled Trials ISRCTN24346473. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 15. See the NIHR Journals Library website for further project information.

Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial

BackgroundAntibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting.Methods/designA cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no).DiscussionThis is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results.Trial registrationNetherlands Trial Register, Trial NL5054. Registered 29 August 2018.

PMD18 A COST-EFFECTIVENESS AND BUDGET IMPACT ANALYSIS OF C-REACTIVE PROTEIN POINT-OF-CARE TESTING TO GUIDE ANTIBIOTIC PRESCRIBING FOR RESPIRATORY TRACT INFECTIONS IN PRIMARY CARE SETTINGS IN IRELAND

The problem of antimicrobial resistance (AMR) is substantial, exacerbated by excessive and inappropriate antibiotic prescribing. Approximately 60% of antibiotics issued in primary care are for respiratory tract infections (RTIs), which are mostly self-limiting and do not require antibiotics. Point-of-care testing (POCT) devices that measure C-reactive protein (CRP) – a biomarker for infection – can be used to guide and ultimately reduce prescribing. We performed a cost-effectiveness and budget impact analysis of a national programme of CRP POCT to improve antimicrobial stewardship for RTIs in primary care in Ireland. We compared CRP POCT – with and without communication skills training of General Practitioners – against usual care. We performed a network meta-analysis to establish clinical effectiveness and developed a probabilistic decision tree to investigate cost-effectiveness and budget impact from the perspective of the healthcare system. The model considered outcomes for the Irish population over five years. Inputs were synthesised from published studies. Cost-effectiveness was estimated using cost-per-prescription avoided. CRP POCT with/out communication training was more costly and effective than usual care, although some uncertainty in long-term effectiveness was observed. CRP POCT without communication training was dominated, while the combined intervention had a cost-per-prescription avoided of €111 (95% CI €45 to €243) versus usual care. The budget impact was costly over five years, estimated at €4.5 million (95% CI €-22.8 to €34.8 million) and €23.9 million (95% CI €5.1 to €43.8 million) with/out communication training. The findings were robust to sensitivity analyses. CRP POCT is most cost-effective when combined with communication training. However, the budget impact is costly, and there’s limited evidence that the effect is sustained in the long-term, suggesting the device may not reflect value for money or sufficiently address the growing problem of AMR. CRP POCT should be considered alongside a suite of interventions aimed at improving antimicrobial stewardship.