Dataset Information

Point-of-care C-reactive protein test results in acute infections in children in primary care: an observational study.

ABSTRACT:

Background

Acute infections are a common reason for children to consult primary care. Serious infections are rare but differentiating them from self-limiting illnesses remains challenging. This can lead to inappropriate antibiotic prescribing. Point-of-care C-reactive protein testing is used to guide antibiotic prescribing in adults. However, in children its use remains unclear. The purpose of this study was to assess point-of-care CRP test levels with respect to patients' characteristics, care setting, preliminary diagnosis, and management.

Methods

A prospective observational study was performed in children with an acute infection presenting to ambulatory care in Belgium.

Results

In this study 8280 cases were analysed, of which 6552 had a point-of-care CRP value available. A total of 276 physicians participated. The median patient age was 1.98 years (IQR 0.97 to 4.17), 37% of children presented to a general practitioner, 33% to a paediatric out-patient clinic, and 30% to the emergency department. A total of 131 different preliminary diagnoses were found, with acute upper airway infection as the most frequent. In 6% (n = 513) patients were diagnosed with a serious infection. The most common serious infection was pneumonia. Antibiotics were prescribed in 28% (n = 2030) of all episodes. The median CRP over all infectious episodes was 10 mg/L (IQR < 5-29). Children below 5 years of age and those presenting to a paediatrician had a higher median CRP. Median CRP in patients with serious infections was 21 mg/L (IQR 6 to 63.5). Pneumonia had a median CRP of 48 mg/L (IQR 13-113). In the episodes with antibiotics prescription, median CRP level was 29 mg/L (IQR 10-58) compared to 7 mg/L (IQR < 5-19) when they were not prescribed.

Conclusion

A low POC CRP as a standalone tool did not seem to be sufficient to rule out serious infections, but its potential in assessing serious infections could increase when integrated in a clinical decision rule.

Trial registration

ClinicalTrials.gov Identifier: NCT02024282 (registered on 31/12/2013).

SUBMITTER: De Rop L

PROVIDER: S-EPMC9635070 | biostudies-literature | 2022 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Point-of-care C-reactive protein test results in acute infections in children in primary care: an observational study.

De Rop Liselore L De Burghgraeve Tine T De Sutter An A Buntinx Frank F Verbakel Jan Y JY

BMC pediatrics 20221104 1

<h4>Background</h4>Acute infections are a common reason for children to consult primary care. Serious infections are rare but differentiating them from self-limiting illnesses remains challenging. This can lead to inappropriate antibiotic prescribing. Point-of-care C-reactive protein testing is used to guide antibiotic prescribing in adults. However, in children its use remains unclear. The purpose of this study was to assess point-of-care CRP test levels with respect to patients' characteristic ...[more]

PMID: 36333682

Similar Datasets

Project description:BackgroundInappropriate antibiotic use for acute respiratory tract infections is common in primary health care, but distinguishing serious from self-limiting infections is difficult, particularly in low-resource settings. We assessed whether C-reactive protein point-of-care testing can safely reduce antibiotic use in patients with non-severe acute respiratory tract infections in Vietnam.MethodWe did a multicentre open-label randomised controlled trial in ten primary health-care centres in northern Vietnam. Patients aged 1-65 years with at least one focal and one systemic symptom of acute respiratory tract infection were assigned 1:1 to receive either C-reactive protein point-of-care testing or routine care, following which antibiotic prescribing decisions were made. Patients with severe acute respiratory tract infection were excluded. Enrolled patients were reassessed on day 3, 4, or 5, and on day 14 a structured telephone interview was done blind to the intervention. Randomised assignments were concealed from prescribers and patients but not masked as the test result was used to assist treatment decisions. The primary outcome was antibiotic use within 14 days of follow-up. All analyses were prespecified in the protocol and the statistical analysis plan. All analyses were done on the intention-to-treat population and the analysis of the primary endpoint was repeated in the per-protocol population. This trial is registered under number NCT01918579.FindingsBetween March 17, 2014, and July 3, 2015, 2037 patients (1028 children and 1009 adults) were enrolled and randomised. One adult patient withdrew immediately after randomisation. 1017 patients were assigned to receive C-reactive protein point-of-care testing, and 1019 patients were assigned to receive routine care. 115 patients in the C-reactive protein point-of-care group and 72 patients in the routine care group were excluded in the intention-to-treat analysis due to missing primary endpoint. The number of patients who used antibiotics within 14 days was 581 (64%) of 902 patients in the C-reactive protein group versus 738 (78%) of 947 patients in the control group (odds ratio [OR] 0·49, 95% CI 0·40-0·61; p<0·0001). Highly significant differences were seen in both children and adults, with substantial heterogeneity of the intervention effect across the 10 sites (I(2)=84%, 95% CI 66-96). 140 patients in the C-reactive protein group and 137 patients in the routine care group missed the urine test on day 3, 4, or 5. Antibiotic activity in urine on day 3, 4, or 5 was found in 267 (30%) of 877 patients in the C-reactive protein group versus 314 (36%) of 882 patients in the routine treatment group (OR 0·78, 95% CI 0·63-0·95; p=0·015). Time to resolution of symptoms was similar in both groups. Adverse events were rare, with no deaths and a total of 14 hospital admissions (six in the C-reactive protein group and eight in the control group).InterpretationC-reactive protein point-of-care testing reduced antibiotic use for non-severe acute respiratory tract infection without compromising patients' recovery in primary health care in Vietnam. Health-care providers might have become familiar with the clinical picture of low C-reactive protein, leading to reduction in antibiotic prescribing in both groups, but this would have led to a reduction in observed effect, rather than overestimation. Qualitative analysis is needed to address differences in context in order to implement this strategy to improve rational antibiotic use for patients with acute respiratory infection in low-income and middle-income countries.FundingWellcome Trust, UK, and Global Antibiotic Resistance Partnership, USA.

Project description:BackgroundThe use of point of care (POC) tests varies across Europe, but research into what drives this variability is lacking. Focusing on CRP POC tests, we aimed to understand what factors contribute to high versus low adoption of the tests, and also to explore whether they are used in children.MethodsWe used a comparative qualitative case study approach to explore the implementation of CRP POC tests in the Netherlands and England. These countries were selected because although they have similar primary healthcare systems, the availability of CRP POC tests in General Practices is very different, being very high in the former and rare in the latter. The study design and analysis were informed by the non-adoption, abandonment, spread, scale-up and sustainability (NASSS) framework. Data were collected through a review of documents and interviews with stakeholders. Documents were identified through a scoping literature review, search of websites, and stakeholder recommendation. Stakeholders were selected purposively initially, and then by snowballing. Data were analysed thematically.ResultsSixty-five documents were reviewed and 21 interviews were conducted. The difference in the availability of CRP POC tests is mainly because of differences at the wider national context level. In the two countries, early adopters of the tests advocated for their implementation through the generation of robust evidence and by engaging with all relevant stakeholders. This led to the inclusion of CRP POC tests in clinical guidelines in both countries. In the Netherlands, this mandated their reimbursement in accordance with Dutch regulations. Moreover, the prevailing better integration of health services enabled operational support from laboratories to GP practices. In England, the funding constraints of the National Health Service and the prioritization of alternative and less expensive antimicrobial stewardship interventions prevented the development of a reimbursement scheme. In addition, the lack of integration between health services limits the operational support to GP practices. In both countries, the availability of CRP POC tests for the management of children is a by-product of the test being available for adults. The tests are less used in children mainly because of concerns regarding their accuracy in this age-group.ConclusionsThe engagement of early adopters combined with a more favourable and receptive macro level environment, including the role of clinical guidelines and their developers in determining which interventions are reimbursed and the operational support from laboratories to GP practices, led to the greater adoption of the tests in the Netherlands. In both countries, CRP POC tests, when available, are less used less in children. Organisations considering introducing POC tests into primary care settings need to consider how their implementation fits into the wider health system context to ensure achievable plans.

Project description:ObjectivesPoint-of-care tests (POCTs) for infection offer accurate rapid diagnostics but do not consistently improve antibiotic stewardship (ASP) of suspected ventilator-associated pneumonia. We aimed to measure the effect of a negative PCR-POCT result on intensive care unit (ICU) clinicians' antibiotic decisions and the additional effects of patient trajectory and cognitive-behavioural factors (clinician intuition, dis/interest in POCT, risk averseness).DesignObservational cohort simulation study.SettingICU.Participants70 ICU consultants/trainees working in UK-based teaching hospitals.MethodsClinicians saw four case vignettes describing patients who had completed a course of antibiotics for respiratory infection. Vignettes comprised clinical and biological data (ie, white cell count, C reactive protein), varied to create four trajectories: clinico-biological improvement (the 'improvement' case), clinico-biological worsening ('worsening'), clinical improvement/biological worsening ('discordant clin better'), clinical worsening/biological improvement ('discordant clin worse'). Based on this, clinicians made an initial antibiotics decision (stop/continue) and rated confidence (6-point Likert scale). A PCR-based POCT was then offered, which clinicians could accept or decline. All clinicians (including those who declined) were shown the result, which was negative. Clinicians updated their antibiotics decision and confidence.MeasuresAntibiotics decisions and confidence were compared pre-POCT versus post-POCT, per vignette.ResultsA negative POCT result increased the proportion of stop decisions (54% pre-POCT vs 70% post-POCT, χ2(1)=25.82, p<0.001, w=0.32) in all vignettes except improvement (already high), most notably in discordant clin worse (49% pre-POCT vs 74% post-POCT). In a linear regression, factors that significantly reduced clinicians' inclination to stop antibiotics were a worsening trajectory (b=-0.73 (-1.33, -0.14), p=0.015), initial confidence in continuing (b=0.66 (0.56, 0.76), p<0.001) and involuntary receipt of POCT results (clinicians who accepted the POCT were more inclined to stop than clinicians who declined it, b=1.30 (0.58, 2.02), p<0.001). Clinician risk averseness was not found to influence antibiotic decisions (b=-0.01 (-0.12, 0.10), p=0.872).ConclusionsA negative PCR-POCT result can encourage antibiotic cessation in ICU, notably in cases of clinical worsening (where the inclination might otherwise be to continue). This effect may be reduced by high clinician confidence to continue and/or disinterest in POCT, perhaps due to low trust/perceived utility. Such cognitive-behavioural and trajectorial factors warrant greater consideration in future ASP study design.

Dataset Information

Point-of-care C-reactive protein test results in acute infections in children in primary care: an observational study.

Background

Methods

Results

Conclusion

Trial registration

Publications

Point-of-care C-reactive protein test results in acute infections in children in primary care: an observational study.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets