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Should all acutely ill children in primary care be tested with point-of-care CRP : a cluster randomised trial

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Abstract
Background: Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment. Methods: Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature ≥ 40 °C, diarrhoea and age 12–30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L. Results: Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 % (95 % CI, 77.8–82.0 %). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 % vs. 0.14 %, P = 0.88). Only one child with a CRP < 5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 %, 95 % CI, 19.6–45.6 %) had a CRP < 5 mg/L. Conclusions: CRP testing should be restricted to children at higher risk after clinical assessment. A CRP < 5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals.
Keywords
C-reactive protein, Point-of-care, Child, Primary care, Serious infection: C-REACTIVE PROTEIN, RESPIRATORY-TRACT INFECTIONS, DIAGNOSTIC-ACCURACY, SERIOUS INFECTIONS, CLINICIAN, SYMPTOMS, SIGNS

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Chicago
Verbakel, Jan Y, Marieke Lemiengre, Tine De Burghgraeve, An De Sutter, Bert Aertgeerts, Bethany Shinkins, Rafael Perera, David Mant, Ann Van den Bruel, and Frank Buntinx. 2016. “Should All Acutely Ill Children in Primary Care Be Tested with Point-of-care CRP : a Cluster Randomised Trial.” Bmc Medicine 14.
APA
Verbakel, J. Y., Lemiengre, M., De Burghgraeve, T., De Sutter, A., Aertgeerts, B., Shinkins, B., Perera, R., et al. (2016). Should all acutely ill children in primary care be tested with point-of-care CRP : a cluster randomised trial. BMC MEDICINE, 14.
Vancouver
1.
Verbakel JY, Lemiengre M, De Burghgraeve T, De Sutter A, Aertgeerts B, Shinkins B, et al. Should all acutely ill children in primary care be tested with point-of-care CRP : a cluster randomised trial. BMC MEDICINE. 2016;14.
MLA
Verbakel, Jan Y, Marieke Lemiengre, Tine De Burghgraeve, et al. “Should All Acutely Ill Children in Primary Care Be Tested with Point-of-care CRP : a Cluster Randomised Trial.” BMC MEDICINE 14 (2016): n. pag. Print.
@article{8108111,
  abstract     = {Background: Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment.
Methods: Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature\,\ensuremath{\geq}\,40 {\textdegree}C, diarrhoea and age 12--30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L.
Results: Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 \% (95 \% CI, 77.8--82.0 \%). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 \% vs. 0.14 \%, P\,=\,0.88). Only one child with a CRP\,{\textlangle}\,5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 \%, 95 \% CI, 19.6--45.6 \%) had a CRP\,{\textlangle}\,5 mg/L.
Conclusions: CRP testing should be restricted to children at higher risk after clinical assessment. A CRP\,{\textlangle}\,5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals.},
  articleno    = {131},
  author       = {Verbakel, Jan Y and Lemiengre, Marieke and De Burghgraeve, Tine and De Sutter, An and Aertgeerts, Bert and Shinkins, Bethany and Perera, Rafael and Mant, David and Van den Bruel, Ann and Buntinx, Frank},
  issn         = {1741-7015},
  journal      = {BMC MEDICINE},
  language     = {eng},
  pages        = {7},
  title        = {Should all acutely ill children in primary care be tested with point-of-care CRP : a cluster randomised trial},
  url          = {http://dx.doi.org/10.1186/s12916-016-0679-2},
  volume       = {14},
  year         = {2016},
}

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