Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis

Verbakel, Jan Y; Lee, Joseph; Goyder, Clare; Tan, Pui San; Ananthakumar, Thanusha; Turner, P; Hayward, Gail; Bruel, Ann Van den

doi:10.1136/bmjopen-2018-025036

Cited by 54 publications

(68 citation statements)

References 60 publications

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“…One review focused on RTIs in primary care, but the results published six years ago were limited by a small number of studies of generally small samples that included mostly adults [ 25 ]. The second review with a broader scope included all acute infections presenting to ambulatory care [ 26 ]. We performed a systematic review to assess the evidence on the clinical effectiveness of CRP-POCT compared with usual care in reducing antibiotic prescribing for RTIs in primary care.…”

Section: Introductionmentioning

confidence: 99%

Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

et al. 2020

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C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

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Section: Introductionmentioning

confidence: 99%

Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

et al. 2020

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“…A large study in Vietnam showed a reduction of antibiotic use after CRP testing for nonsevere acute RTIs in adults as well as in children [26]. In the European ambulatory care setting, there is evidence that CRP testing can reduce immediate antibiotic prescription in children when appropriate guidance is provided to the healthcare professional [27,28]. A randomised controlled trial from Switzerland studied PCT-guided treatment, but found no effect on antibiotic prescription rates [29].…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a clinical decision rule to guide antibiotic prescription in children with suspected lower respiratory tract infection in The Netherlands: A stepped-wedge cluster randomised trial

Maat

Peeters²,

Nieboer

et al. 2020

PLoS Med

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Background Optimising the use of antibiotics is a key component of antibiotic stewardship. Respiratory tract infections (RTIs) are the most common reason for antibiotic prescription in children, even though most of these infections in children under 5 years are viral. This study aims to safely reduce antibiotic prescriptions in children under 5 years with suspected lower RTI at the emergency department (ED), by implementing a clinical decision rule. Methods and findings In a stepped-wedge cluster randomised trial, we included children aged 1-60 months presenting with fever and cough or dyspnoea to 8 EDs in The Netherlands. The EDs were of varying sizes, from diverse geographic and demographic regions, and of different hospital types (tertiary versus general). In the pre-intervention phase, children received usual care, according to the Dutch and NICE guidelines for febrile children. During the intervention phase, a validated clinical prediction model (Feverkidstool) including clinical characteristics and C-reactive protein (CRP) was implemented as a decision rule guiding antibiotic prescription. The intervention was that antibiotics were withheld in children with a low or intermediate predicted risk of bacterial pneumonia (�10%, based on Feverkidstool). Co-primary outcomes were antibiotic prescription rate and strategy failure. Strategy failure was defined

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Section: Introductionmentioning

confidence: 99%

“…This systematic review forms part of a series of analyses from a larger overall review (in progress) which will assess the overall quantitative impact of all POCTs in ambulatory care. This main search was originally performed on 19 November 2015 and then updated on 21 March 2017, following this subgroup analyses on CRP13 and influenza14 were published. Studies based in resource poor settings form another subgroup analyses from the overall review and will also be published separately.…”

Section: Introductionmentioning

confidence: 99%

Impact of point-of-care panel tests in ambulatory care: a systematic review and meta-analysis

et al. 2020

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Strengths and limitations of this study ► This study was conducted robustly, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using a comprehensive search strategy in the major medical databases, and selection and quality assessment performed by two independent reviewers. ► It offers results on the impact of panel point-of-care tests (POCTs), rather than just their accuracy. ► Included studies were relatively small, and most notably for mortality, may be underpowered to detect clinically relevant differences between laboratory and POCTs. ► Statistical and clinical heterogeneity is evident within our meta-analysis, however the meta-analysis was considered carefully and heterogeneity reduced where possible by ensuring that studies of cardiac and general panel tests were not combined; moreover, we did not combine the before-after study (which also had a high risk of bias) with randomisedcontrolled trials. ► Four studies excluded critically ill patients and patients with myocardial infarction, which may have biased mortality data. AbStrACtObjectives This article summarises all the available evidence on the impact of introducing blood-based pointof-care panel testing (POCT) in ambulatory care on patient outcomes and healthcare processes.Design Systematic review and meta-analysis of randomised-controlled trials and before-after studies. Data sources Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, Database of Abstracts of Reviews and Effects, Science Citation Index from inception to 22 October 2019.Eligibility criteria for selecting studies Included studies were based in ambulatory care and compared POCT with laboratory testing. The primary outcome was the time to decision regarding disposition that is, admission/ referral termed disposition decision (DD) time. Secondary outcomes included length of stay (LOS) at the ambulatory care unit/practice and mortality. results 19 562 patients from nine studies were included in the review, eight of these were randomised-controlled trials, and one was a before-after study. All the studies were based in either emergency departments or the ambulance service; no studies were from primary care settings. General panel tests performed at the POCT resulted in DDs being made 40 min faster (95% CI −42.2 to −36.6, I 2 =0%) compared with the group receiving usual care, including central laboratory testing. This in turn resulted in a reduction in LOS for patients who were subsequently discharged by 34 min (95% CI −63.7 to −5.16). No significant difference in mortality was reported.Discussion Although statistical and clinical heterogeneity is evident and only a small number of studies were included in the meta-analysis, our results suggest that POCTs might lead to faster discharge decisions. Future research should be performed in primary care and identify how POCTs can contribute meaningful changes to patient care rather than focusing on healthcare processes. PrOSPErO registration number CRD42016035426.

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Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis

Cited by 54 publications

References 60 publications

Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

Evaluation of a clinical decision rule to guide antibiotic prescription in children with suspected lower respiratory tract infection in The Netherlands: A stepped-wedge cluster randomised trial

Impact of point-of-care panel tests in ambulatory care: a systematic review and meta-analysis

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