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

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

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

4. Common conditions in GP1
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

5. Antibiotics for RTI
Cosby Lancet Inf Dis 2007

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

7. Point of care tests – where?
Melbye PCRJ 2011

9. CRP POCT decreases antibiotic use for respiratory infections in primary care

10. 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)

12. 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 Netherlands
431 pt LRTI Antibiotics 68% → 39%

13. CRP in RTI– trial evidence
Cals, Ann Fam Med Netherlands
258 pt LRTI & rhinosinusitis Antibiotics 58% → 43%
Little, Lancet 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%

14. 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):.
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Cochrane Database of Systematic Reviews 6 NOV 2014 DOI: / CD pub2

15. 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

16. 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!

17. 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

18. 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

19. 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 )
Miravitlles, Chest 2013
Increased sputum purulence and CRP > 40 mg/l

20. 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

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

22. Thank you
@jochencals
maastrichtuniversity.nl

24. 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

25. Balancing harms and benefits across settings
Cosby Lancet Inf Dis 2007