C-reactive protein-guided antibiotic prescribing for COPD exacerbations: a qualitative evaluation.

Antibiotics are prescribed to >70% of patients presenting in primary care with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The PACE randomised controlled trial found that a C-reactive protein point-of-care test (CRP-POCT) management strategy for AECOPD in primary care resulted in a 20% reduction in patient-reported antibiotic consumption over 4 weeks. To understand perceptions of the value of CRP-POCT for guiding antibiotic prescribing for AECOPD; explore possible mechanisms, mediators, and pathways to effects; and identify potential barriers and facilitators to implementation from the perspectives of patients and clinicians. Qualitative process evaluation in UK general practices. Semi-structured telephone interviews with 20 patients presenting with an AECOPD and 20 primary care staff, purposively sampled from the PACE study. Interviews were audio-recorded, transcribed, and analysed using framework analysis. Patients and clinicians felt that CRP-POCT was useful in guiding clinicians' antibiotic prescribing decisions for AECOPD, and were positive about introduction of the test in routine care. The CRP-POCT enhanced clinician confidence in antibiotic prescribing decisions, reduced decisional ambiguity, and facilitated communication with patients. Some clinicians thought the CRP-POCT should be routinely used in consultations for AECOPD; others favoured use only when there was decisional uncertainty. CRP-POCT cartridge preparation time and cost were potential barriers to implementation. CRP-POCT-guided antibiotic prescribing for AECOPD had high acceptability, but commissioning arrangements and further simplification of the CRP-POCT need attention to facilitate implementation in routine practice.

Phillips R ，Stanton H ，Singh-Mehta A ，Gillespie D ，Bates J ，Gal M ，Thomas-Jones E ，Lowe R ，Hood K ，Llor C ，Melbye H ，Cals J ，White P ，Butler C ，Francis N ... -  《-》

C-reactive protein point-of-care testing for safely reducing antibiotics for acute exacerbations of chronic obstructive pulmonary disease: the PACE RCT.

Francis NA ，Gillespie D ，White P ，Bates J ，Lowe R ，Sewell B ，Phillips R ，Stanton H ，Kirby N ，Wootton M ，Thomas-Jones E ，Hood K ，Llor C ，Cals J ，Melbye H ，Naik G ，Gal M ，Fitzsimmons D ，Alam MF ，Riga E ，Cochrane A ，Butler CC ... -  《-》

General practitioner use of a C-reactive protein point-of-care test to help target antibiotic prescribing in patients with acute exacerbations of chronic obstructive pulmonary disease (the PACE study): study protocol for a randomised controlled trial.

Bates J ，Francis NA ，White P ，Gillespie D ，Thomas-Jones E ，Breen R ，Kirby N ，Hood K ，Gal M ，Phillips R ，Naik G ，Cals J ，Llor C ，Melbye H ，Wootton M ，Riga E ，Cochrane A ，Howe R ，Fitzsimmons D ，Sewell B ，Alam MF ，Butler CC ... -  《Trials》

Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England.

To explore the knowledge, skills, attitudes and beliefs of general practice staff about C reactive protein (CRP) point-of-care tests (POCTs) in routine general practice and associated barriers and facilitators to implementing it to improve the management of acute cough. A qualitative methodology including interviews and focus groups using the Com-B framework to understand individuals' behaviour to implement CRP POCT in routine general practice. Data were analysed inductively and then aligned to the Com-B framework. A service evaluation of CRP POCT over a 6-month period was previously conducted in randomly selected GP practices from a high prescribing National Health Service Clinicial Commissioning Groups in England. All 11 intervention practices (eight accepting CRPs; three declining CRPs) and the eight control practices, which were not offered CRP POCT, were also invited to interview. A further randomly selected practice not allocated to intervention or control was also invited to participate. Seven of eight accepting CRP, one of three declining CRP and four of nine control practices consented to participate. 12 practices and 26 general practice staff participated; 11 interviews, 3 focus groups and 1 hand-written response. Participants reported that CRP POCT can increase diagnostic certainty for acute cough, inform appropriate management, manage patient expectations for antibiotics, support patient education and improve appropriate antibiotic prescribing. Reported barriers to implementing CRP POCT included: CRP cost, time, easy access to the POCT machine and effects on clinical workflow. Participants with greater CRP use usually had a dedicated staff member with the machine located in their consultation room. CRP POCT can help general practice staff improve patient care and education if incorporated into routine care, but this will need enthusiasts with dedicated POCT instruments or smaller, cheaper, more portable machines. In addition, funding will be needed to support test costs and staff time.

Eley CV ，Sharma A ，Lecky DM ，Lee H ，McNulty CAM ... -  《-》

C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations.

Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD). We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was -0.19 points (two-sided 90% CI, -0.33 to -0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation. CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473.).

Butler CC ，Gillespie D ，White P ，Bates J ，Lowe R ，Thomas-Jones E ，Wootton M ，Hood K ，Phillips R ，Melbye H ，Llor C ，Cals JWL ，Naik G ，Kirby N ，Gal M ，Riga E ，Francis NA ... -  《-》