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Presentation transcript:

@jochencals IPCRG Amsterdam CRP Point of Care Testing: in infections & COPD? @jochencals IPCRG Amsterdam

Conflicts of interest None to declare Principle investigator on 2 CRP trials

IPCRG Research Needs Statement Respiratory tract infections Allergic rhinitis Tobacco dependence Astma COPD Pinnock, PCRJ 2010 Pinnock, PCRJ 2010

Common conditions in GP 1 Upper RTI (R74) 51 /1000 2 Cough (R05) 34/1000 8 Acute sinusitis (R75) 22/1000 9 Acute bronchitis (R78) 12 Otitis media (H71) 16/1000 ~15-20% of GP workload

Antibiotics for RTI Cosby Lancet Inf Dis 2007

Solutions to target overprescribing Disease perspective: Point of care tests Illness perspective: Communication tools Delayed prescribing

Point of care tests – where? Melbye PCRJ 2011

CRP POCT decreases antibiotic use for respiratory infections in primary care

CRP point of care test C-reactieve protein Infection marker Sensitive, non-specific Finger prick, one drop of blood Results < 2-4 minutes (<8 to 250 mg/l)

CRP in RTI– trial evidence Melbye, Tidsskr Nor Laeg 1995 Norway 239 pt LRTI Antibiotics 60% → 56% Diederichsen, Scand J PHC 2000 Denmark 812 pt RTI Antibiotics 46% → 43% Cals, BMJ 2009 Netherlands 431 pt LRTI Antibiotics 68% → 39%

CRP in RTI– trial evidence Cals, Ann Fam Med 2010 Netherlands 258 pt LRTI & rhinosinusitis Antibiotics 58% → 43% Little, Lancet 2013 UK, NL, Belgium, Poland, Spain 4264 pt RTI/acute cough Antibiotics 48% → 33% Andreeva, BMC Fam Pract 2014 Russia 179 pt acute cough/RTI Antibiotics 59% → 38%

Forest plot of comparison: 1 C‐reactive protein ‐ antibiotic prescribing: all trials, outcome: 1.1 C‐reactive protein ‐ antibiotics prescribed at index consultation. All trials (cluster‐RCTs modified sample size):. IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. Cochrane Database of Systematic Reviews 6 NOV 2014 DOI: 10.1002/14651858.CD010130.pub2 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010130.pub2/full#CD010130-fig-0004

CRP in RTI Use of C-reactive protein point-of-care tests as an adjunct to clinical examination likely reduces antibiotic use in primary care patients with acute (lower as well as upper) respiratory infections without affecting patient recovery rates or the duration of illness. However, a possible small increased risk of hospitalisation cannot be ruled out and safety-netting should accompany use of a point-of-care C-reactive protein test. At present C-reactive protein is the only point-of-care biomarker available in primary care settings that may assist in guiding antibiotic prescribing for ARIs Aabenhus, Cochrane Review 2014

CRP assistance Add CRP to clinical findings! no antibiotic < 20 mg/L 20-99 mg/L > 100 mg/L no antibiotic delayed antibiotic antibiotic Add CRP to clinical findings!

Is CRP POCT cost-effective? Cals, J Ev Clin Pract 2010 Netherlands Oppong, BJGP 2013 Europe Hunter, Adv Ther 2014 UK Additional cost pp of the CRP test is outweighed by the associated cost savings and QALY increment associated with a reduction in infections in the long term

Do GPs want CRP POCT? Cross-sectional survey Needs assessment of point of care tests 2771 physicians UK, US, Belgium, the Netherlands and Australia CRP POCT current use: 19% (range 3-45%) CRP POCT future use: 55% (range 38-75%) Howick, BMJ Open 2014

What about CRP POCT in COPD? Limited evidence, no RCTs Strykowksi, Fam Pract 2015 952 patients with acute exacerbation of COPD Interventions: info and meetings or info and meetings + CRP GPs who had access to CRP POCT prescribed significantly less antibiotics (OR 0.35, 95% CI 0.18-0.68) Miravitlles, Chest 2013 Increased sputum purulence and CRP > 40 mg/l

Currently recruited: ~400 patients PICO for The PACE Study Participants Patients consulting with AECOPD in primary care Intervention CRP POCT plus training in interpretation + current best practice Control Current best practice Outcomes COPD health status at 2 weeks Antibiotic consumption within 4 weeks Target sample size: 650 participants from 60 practices Currently recruited: ~400 patients

CRP POCT Effective in reducing AB prescribing (L)RTI / acute cough No trial evidence in AECOPD

Thank you @jochencals j.cals@ maastrichtuniversity.nl

Point of care tests – which test? C-reactive protein Superior to WBC and ESR Differentiates serious from self-limiting infections Quantitative test result within 4 minutes Procalcitonin Promising in hospital Not available as point of care test Melbye Scan J PHC 1988, Hopstaken BJGP 2003, Cals JAMA 2010

Balancing harms and benefits across settings Cosby Lancet Inf Dis 2007