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Point-of-care CRP matters : normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care : a cluster randomized controlled trial

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Abstract
Objective: Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians' (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines. Design: Cluster randomized controlled trial. Setting: Primary care, Flanders, Belgium. Intervention: Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP. Subjects: Acutely ill children consulting their FP. Main outcome measure: Immediate antibiotic prescribing. Results: 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aUR) 0.54 (95% Confidence Interval (CI) 0.33-0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11-0.50) or to withhold (aOR 031 (95%CI 0.17-037)). Elevated CRP levels did not increase antibiotic prescribing. Conclusion: Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.
Keywords
child, acute disease, Anti-Bacterial Agents/therapeutic use, C-reactive protein/analysis, point-of-care-systems, Randomized controlled trial, C-REACTIVE PROTEIN, RESPIRATORY-TRACT INFECTIONS, PRIMARY-HEALTH-CARE, ACUTE-OTITIS-MEDIA, PATIENTS EXPECTATIONS, DOCTORS PERCEPTIONS, GENERAL-PRACTICE, GUIDELINES, ADHERENCE, PRESCRIPTION

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Chicago
Lemiengre, Marieke, Jan Y Verbakel, Roos Colman, Kaatje Van Roy, Tine De Burghgraeve, Frank Buntinx, Bert Aertgeerts, Frans De Baets, and An De Sutter. 2018. “Point-of-care CRP Matters : Normal CRP Levels Reduce Immediate Antibiotic Prescribing for Acutely Ill Children in Primary Care : a Cluster Randomized Controlled Trial.” Scandinavian Journal of Primary Health Care 36 (4): 423–436.
APA
Lemiengre, M., Verbakel, J. Y., Colman, R., Van Roy, K., De Burghgraeve, T., Buntinx, F., Aertgeerts, B., et al. (2018). Point-of-care CRP matters : normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care : a cluster randomized controlled trial. SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE, 36(4), 423–436.
Vancouver
1.
Lemiengre M, Verbakel JY, Colman R, Van Roy K, De Burghgraeve T, Buntinx F, et al. Point-of-care CRP matters : normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care : a cluster randomized controlled trial. SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE. 2018;36(4):423–36.
MLA
Lemiengre, Marieke et al. “Point-of-care CRP Matters : Normal CRP Levels Reduce Immediate Antibiotic Prescribing for Acutely Ill Children in Primary Care : a Cluster Randomized Controlled Trial.” SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE 36.4 (2018): 423–436. Print.
@article{8583978,
  abstract     = {Objective: Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians' (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines. 
Design: Cluster randomized controlled trial. 
Setting: Primary care, Flanders, Belgium. 
Intervention: Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP. 
Subjects: Acutely ill children consulting their FP. 
Main outcome measure: Immediate antibiotic prescribing. 
Results: 2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aUR) 0.54 (95\% Confidence Interval (CI) 0.33-0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95\%CI 0.11-0.50) or to withhold (aOR 031 (95\%CI 0.17-037)). Elevated CRP levels did not increase antibiotic prescribing. 
Conclusion: Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.},
  author       = {Lemiengre, Marieke and Verbakel, Jan Y and Colman, Roos and Van Roy, Kaatje and De Burghgraeve, Tine and Buntinx, Frank and Aertgeerts, Bert and De Baets, Frans and De Sutter, An},
  issn         = {0281-3432},
  journal      = {SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE},
  language     = {eng},
  number       = {4},
  pages        = {423--436},
  title        = {Point-of-care CRP matters : normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care : a cluster randomized controlled trial},
  url          = {http://dx.doi.org/10.1080/02813432.2018.1529900},
  volume       = {36},
  year         = {2018},
}

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