From the Journals

C-reactive protein testing reduced antibiotic prescribing in patients with COPD exacerbation



For primary care patients with acute exacerbations of chronic obstructive pulmonary disease (COPD), point-of-care C-reactive protein testing reduced antibiotic use with no evidence of harm, according to a recent randomized, controlled trial.

Point-of-care C-reactive protein (CRP) testing led to fewer antibiotic prescriptions at the initial consultation, according to investigators participating in the PACE study, a multicenter, open-label trial of more than 600 patients with COPD enrolled at one of 86 general practices in the United Kingdom.

Patient-reported antibiotic use over the next 4 weeks was more than 20 percentage points lower for the group managed with the point-of-care strategy, compared with those who received usual care, according to the investigators, led by Christopher C. Butler, FMedSci, of the Nuffield Department of Primary Care Health Sciences at the University of Oxford (England).

Less antibiotic use and fewer prescriptions did not compromise patient-reported, disease-specific quality of life, added Dr. Butler and colleagues. Their report appears in the New England Journal of Medicine.

In the United States and in Europe, more than 80% of COPD patients with acute exacerbations will receive an antibiotic prescription, according to Dr. Butler and coauthors.

“Although many patients who have acute exacerbations of COPD are helped by these treatments, others are not,” wrote the investigators, noting that in one hospital-based study, about one in five such exacerbations were thought to be due to noninfectious causes.

The present study included patients at least 40 years of age who presented to a primary care practice with an acute exacerbation and at least one of the three Anthonisen criteria (increased dyspnea, sputum production, and sputum purulence) intended to guide antibiotic therapy in COPD. A total of 325 were randomly assigned to the CRP testing group, and 324 to a group that received just usual care.

Antibiotic use was reported by fewer patients in the CRP testing group, compared with the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31, 95% confidence interval, 0.20-0.47), the investigators reported.

Only 47.7% of patients in the CRP-guided group received antibiotic prescriptions at the initial consultation, vs. 69.7% of patients in the usual care group.

Hospitalizations over 6 months of follow-up were reported for 8.6% and 9.3% of patients in the CRP-guided and usual-care groups, respectively, while diagnoses of pneumonia were recorded for 3.0% and 4.0%. There was no clinically important difference between groups in the rate of antibiotic-related adverse effects.

“The evidence from our trial suggests that CRP-guided antibiotic prescribing for COPD exacerbations in primary care clinics may reduce patient-reported use of antibiotics and the prescribing of antibiotics by clinicians,” Dr. Butler and colleagues said in a discussion of these results.

Findings from the study by Dr. Butler and colleagues are “compelling enough” to support C-reactive protein (CRP) testing to guide antibiotic use in patient who have acute exacerbations of COPD, wrote the authors of an accompanying editorial.

“The trial achieved its objective, which was to show that CRP testing safely reduces antibiotic use,” stated Allan S. Brett, MD, and Majdi N. Al-Hasan, MB,BS, of the department of medicine at the University of South Carolina, Columbia.

Point-of-care testing of CRP could be applied even more broadly in clinical practice, Dr. Brett and Dr. Al-Hasan wrote, since testing has been shown to reduce prescribing of antibiotics for suspected lower respiratory tract infections and other common presentations in patients with no COPD.

“Whether primary care practices in the United States would embrace point-of-care CRP testing is another matter, given the regulatory requirements for in-office laboratory testing and uncertainty about reimbursement,” they noted.

Reduced antibiotic prescribing in patients with COPD likely has certain benefits, including reducing risk of Clostridioides difficile colitis, according to the authors.

By contrast, the current study did not determine which COPD patients might benefit from antibiotics, if any, nor which antibiotic might be warranted for those patients.

The study was supported by the Health Technology Assessment Program of the UK National Institute for Health Research. Dr. Butler reported disclosures related to Roche Molecular Systems and Roche Molecular Diagnostics, among others.

SOURCE: Butler CC et al. N Engl J Med. 2019 Jul 10;381:111-20. doi: 10.1056/NEJMoa1803185.

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