Clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice

Detection of serum human neutrophil lipocalin is an effective biomarker for the diagnosis and monitoring of children with bacterial infection

BACKGROUND

The study aimed to investigate the diagnostic efficiency of human neutrophil lipocalin (HNL) in bacterial infections in children.

METHODS

This study included 49 pediatric patients with bacterial infections, 37 patients with viral infections, 30 patients with autoimmune diseases (AID) and 41 healthy controls (HCs). HNL, procalcitonin (PCT), C-reactive protein (CRP), white blood cell (WBC) and neutrophil counts were detected in the initial diagnosis and the following days.

RESULTS

In the patients with bacterial infections, the levels of HNL, PCT, CRP, WBC and neutrophils were significantly increased than that of disease controls and HCs. The dynamic of these markers was monitored during antibiotic treatment. The level of HNL was decreased rapidly in patients with effective treatment, but maintained at high levels in deteriorated patients according to the clinical progression.

CONCLUSIONS

HNL detection is an effective biomarker to identify bacterial infections from viral infections and other AIDs, and has potential value to evaluate the effect of antibiotic treatment in pediatric patients.

Clinical presentation, microbiological aetiology and disease course in patients with flu-like illness: a post hoc analysis of randomised controlled trial data

BACKGROUND

There is little evidence about the relationship between aetiology, illness severity, and clinical course of respiratory tract infections (RTIs) in primary care. Understanding these associations would aid in the development of effective management strategies for these infections.

AIM

To investigate whether clinical presentation and illness course differ between RTIs where a viral pathogen was detected and those where a potential bacterial pathogen was found.

DESIGN AND SETTING

Post hoc analysis of data from a pragmatic randomised trial on the effects of oseltamivir in patients with flu-like illness in primary care (n = 3266) in 15 European countries.

METHOD

Patient characteristics and their signs and symptoms of disease were registered at baseline. Nasopharyngeal (adults) or nasal and pharyngeal (children) swabs were taken for polymerase chain reaction analysis. Patients were followed up until 28 days after inclusion. Regression models and Kaplan-Meier curves were used to analyse the relationship between aetiology, clinical presentation at baseline, and course of disease including complications.

RESULTS

Except for a less prominent congested nose (odds ratio [OR] 0.55, 95% confidence interval [CI] = 0.35 to 0.86) and acute cough (OR 0.42, 95% CI = 0.27 to 0.65) in patients with flu-like illness in whom a possible bacterial pathogen was isolated, there were no clear clinical differences in presentations between those with a possible bacterial aetiology compared with those with a viral aetiology. Also, course of disease and complications were not related to aetiology.

CONCLUSION

Given current available microbiological tests and antimicrobial treatments, and outside pandemics such as COVID-19, microbiological testing in primary care patients with flu-like illness seems to have limited value. A wait-and-see policy in most of these patients with flu-like illness seems the best option.

C-reactive protein cut-offs used for acute respiratory infections in Danish general practice

Background

GPs can use the C-reactive protein (CRP) point-of-care test (POCT) to assist when deciding whether to prescribe antibiotics for patients with acute respiratory tract infections (RTIs).

Aim

To estimate the CRP cut-off levels that Danish GPs use to guide antibiotic prescribing for patients presenting with different signs and symptoms of RTIs.

Design & setting

A cross-sectional study conducted in general practice in Denmark.

Method

During the winters of 2017 and 2018, 143 GPs and their staff registered consecutive patients with symptoms of an RTI according to the Audit Project Odense (APO) method. CRP cut-offs were estimated as the lowest level at which half of the patients were prescribed an antibiotic.

Results

In total, 7813 patients were diagnosed with an RTI, of whom 4617 (59%) had a CRP test performed. At least 25% of the patients were prescribed an antibiotic when the CRP level was >20 mg/L, at least 50% when CRP was >40 mg/L, and at least 75% when CRP was >50 mg/L. Lower thresholds were identified for patients aged ≥65 years and those presenting with a fever, poor general appearance, dyspnoea, abnormal lung auscultation, or ear/facial pain, and if the duration of symptoms was either short (≤1 day) or long (>14 days).

Conclusion

More than half of patients presenting to Danish general practice with symptoms of an RTI have a CRP test performed. At CRP levels >40 mg/L, the majority of patients have an antibiotic prescribed.

Diagnosis and Monitoring of Acute Infections with Emphasis on the Novel Biomarker Human Neutrophil Lipocalin

Background

Acute infections affect all of us at least once or twice a year. Sometimes the infection prompts a visit to our doctor, and the question asked by the patient and the doctor is whether the infection should be treated with antibiotics or not. This is an important question because unnecessary prescription of antibiotics adds to the increasing problem of antibiotics resistance. Objective means to determine whether the infection is caused by bacteria or virus, therefore, are necessary tools for the doctor.

Content

White blood cell counts, C-reactive protein, and other acute-phase reactants in blood are important tools and are commonly used, but unfortunately lack in sensitivity and specificity. In this review we describe some novel biomarkers with increased clinical performance in this regard. The superior biomarker is human neutrophil lipocalin (HNL), a protein released from activated blood neutrophils. HNL may be measured in serum, plasma, or in whole blood after activation with a neutrophil activator. The diagnostic accuracy in the distinction between bacterial and viral acute infections was shown to be in the range of 90%–95% when measured in serum or activated whole blood.

Summary

A point-of-care assay for the measurement of HNL in whole blood is currently being developed, which will allow the diagnosis of acute infections within 5–10 min. For certain indications, HNL measurement may be complemented by 1 or 2 other biomarkers, which may increase the diagnostic discrimination between bacterial and viral infections even further.

HNL (Human Neutrophil Lipocalin) and a multimarker approach to the distinction between bacterial and viral infections

OBJECTIVES

The distinction between bacterial and viral causes of acute infections is a major clinical challenge. In this report we investigate the diagnostic performance in this regard of nine candidate biomarkers together with HNL (Human Neutrophil Lipocalin).

METHODS

Blood was obtained from patients with symptoms of infectious (n = 581). HNL was measured in whole blood (B-HNL) after pre-activation with the neutrophil activator fMLP or in plasma (P-HNL). Azurocidin also known as heparin-binding protein (HBP), Calprotectin, PMN-CD64, CRP (C-reactive protein), IP-10 (Interferon γ-induced Protein 10 kDa), PCT (Procalcitonin), TK1 (Thymidine kinase 1), TRAIL (TNF-related apoptosis-inducing ligand) were measured in plasma/serum. Area under the ROC (receiver operating characteristics) curve (AuROC) was used for the evaluation of the clinical performance of the biomarkers.

RESULTS

Side-by-side comparisons of the ten biomarkers showed large difference in the AuROC with B-HNL being the superior biomarker (0.91, 95% CI 0.86-0.95) and with the other nine biomarkers varying from AuROC of 0.63-0.79. The combination of B-HNL with IP-10 and/or TRAIL increased the diagnostic performance further to AuROCs of 0.94-0.97. The AuROCs of the combination of CRP with IP-10 and/or TRAIL were significantly lower than combinations with B-HNL 0.87 (95% CI 0.83-0.91).

CONCLUSION

The diagnostic performance of whole blood activated HNL was superior in the distinction between bacterial or viral infections. The addition of IP-10 and/or TRAIL to the diagnostic algorithm increased the performance of B-HNL further. The rapid analysis of HNL, reflecting bacterial infections, together with biomarkers reflecting viral infections may be the ideal combination of diagnostic biomarkers of acute infections.

Challenges in identifying antibiotic resistance targets for point-of-care diagnostics in general practice

General practitioners stand at the front line of healthcare provision and have a pivotal role in the fight against increasing antibiotic resistance. In this respect, targeted antibiotic prescribing by general practitioners would help reduce the unnecessary use of antibiotics, leading to reduced treatment failures, fewer side-effects for patients and a reduction in the (global) spread of antibiotic resistances. Current 'gold standard' antibiotic resistance detection strategies tend to be slow, taking up to 48 h to obtain a result, although the implementation of point-of-care testing by general practitioners could help achieve the goal of targeted antibiotic prescribing practices. However, deciding on which antibiotic resistances to include in a point-of-care diagnostic is not a trivial task, as outlined in this publication.

Antibiotic treatment failure when consulting patients with respiratory tract infections in general practice. A qualitative study to explore Danish general practitioners' perspectives

BACKGROUND

Prescribing antibiotics for acute respiratory tract infections (RTIs) is common in primary healthcare although most of these infections are of viral origin and antibiotics may not be helpful. Some of these prescriptions will not be associated with a quick recovery, and might be regarded as cases of antibiotic treatment failure (ATF).

OBJECTIVES

We studied antibiotic treatment failure in patients with acute RTIs from a general practitioner (GP) perspective, aiming to explore (i) GPs' views of ATF in primary care; (ii) how ATF influences the doctor-patient relationship; and (iii) GPs' understanding of patients' views of ATF.

METHODS

Qualitative study based on semi-structured, recorded interviews of 18 GPs between August and October 2012. The interviews started with discussion of a unique case of acute RTI involving ATF, followed by a more general reflection of the topic. Interviews were analysed using qualitative content analysis.

RESULTS

In patients with acute RTIs, GPs proposed and agreed to a medical definition of antibiotic treatment failure but believed patients' views to differ significantly from this medical definition. GPs thought ATF affected their daily work only marginally. GPs used many communicative tools to maintain trust with patients in cases of ATF, but they did not consider such incidents to affect the doctor-patient relationship adversely.

CONCLUSION

These findings suggest a possible communication gap between doctors and patients, partly due to a narrow medical definition of ATF. Studies describing patients' views are still missing. General practitioners' experiences and views on antibiotic treatment failure in acute respiratory infections or its effects on the doctor-patient relationship have not been studied previously.

Human neutrophil lipocalin (HNL) as a biomarker of acute infections

The early and accurate discrimination between bacterial and viral causes of acute infections is the key to a better use of antibiotics and will help slow down the fast-growing resistance to commonly used antibiotics. This discrimination is in the vast majority of cases possible to achieve by blood assay of the biomarker human neutrophil lipocalin (HNL), which we showed to be uniquely increased in patients suffering from bacterial infections. In serum, sensitivities and specificities of >90% are achieved in both adults and children. In order to eliminate the need to produce serum, a whole-blood assay with an assay time of <10 min was developed in which blood neutrophils are activated to release HNL. The diagnostic accuracy of this assay also showed sensitivities and specificities of >90% in most infectious diseases and was clearly superior to contemporary assays such as blood neutrophil counts, C-reactive protein, procalcitonin, and expression of CD64 on blood neutrophils. This format lends itself to the development of a point-of-care HNL assay and will be a major step forward to accomplish the goal of accurately diagnosing patients with symptoms of acute infections within 10 min at the emergency room or at the doctor's office.

Andrographis paniculata (Chuān Xīn Lián) for symptomatic relief of acute respiratory tract infections in adults and children: A systematic review and meta-analysis

INTRODUCTION

Antimicrobial resistance (AMR) is a substantial threat to public health. Safe and effective alternatives are required to reduce unnecessary antibiotic prescribing. Andrographis Paniculata (A. Paniculata, Chuān Xīn Lián) has traditionally been used in Indian and Chinese herbal medicine for cough, cold and influenza, suggesting a role in respiratory tract infections (RTIs). This systematic review aimed to evaluate the clinical effectiveness and safety of A. Paniculata for symptoms of acute RTIs (ARTIs).

MATERIALS AND METHODS

English and Chinese databases were searched from their inception to March 2016 for randomised controlled trials (RCTs) evaluating oral A. Paniculata without language barriers (Protocol ID: CRD42016035679). The primary outcomes were improvement in ARTI symptoms and adverse events (AEs). A random effects model was used to pool the mean differences and risk ratio with 95% CI reported. Methodological quality was evaluated using the Cochrane risk of bias tool; two reviewers independently screened eligibility and extracted data.

RESULTS

Thirty-three RCTs (7175 patients) were included. Most trials evaluated A. Paniculata (as a monotherapy and as a herbal mixture) provided commercially but seldom reported manufacturing or quality control details. A. Paniculata improved cough (n = 596, standardised mean difference SMD: -0.39, 95% confidence interval CI [-0.67, -0.10]) and sore throat (n = 314, SMD: -1.13, 95% CI [-1.37, -0.89]) when compared with placebo. A. Paniculata (alone or plus usual care) has a statistically significant effect in improving overall symptoms of ARTIs when compared to placebo, usual care, and other herbal therapies. Evidence also suggested that A. Paniculata (alone or plus usual care) shortened the duration of cough, sore throat and sick leave/time to resolution when compared versus usual care. No major AEs were reported and minor AEs were mainly gastrointestinal. The methodological quality of included trials was overall poor.

CONCLUSIONS

A. Paniculata appears beneficial and safe for relieving ARTI symptoms and shortening time to symptom resolution. However, these findings should be interpreted cautiously owing to poor study quality and heterogeneity. Well-designed trials evaluating the effectiveness and potential to reduce antibiotic use of A. Paniculata are warranted.

Human Neutrophil Lipocalin in Activated Whole Blood Is a Specific and Rapid Diagnostic Biomarker of Bacterial Infections in the Respiratory Tract

The distinction between bacterial and viral causes of infections of the respiratory tract is a major but important clinical challenge. We investigated the diagnostic performance of human neutrophil lipocalin (HNL) in respiratory tract infections compared to those of C-reactive protein (CRP) and procalcitonin (PCT). Patients were recruited from the emergency department and from a primary care unit (n = 162). The clinical diagnosis with regard to bacterial or viral cause of infection was complemented with objective microbiological/serological testing. HNL was measured in whole blood after preactivation with the neutrophil activator formyl-methionine-leucine-phenylalanine (fMLP) (B-HNL), and CRP and PCT were measured in plasma. Head-to-head comparisons of the three biomarkers showed that B-HNL was a superior diagnostic means to distinguish between causes of infections, with areas under the concentration-time curve (AUCs) of receiver operating characteristic (ROC) analysis for HNL of 0.91 (95% confidence interval [CI], 0.83 to 0.96) and 0.92 (95% CI, 0.82 to 0.97) for all respiratory infections and for upper respiratory infections, respectively, compared to 0.72 (95% CI, 0.63 to 0.80) and 0.68 (95% CI, 0.56 to 0.79) for CRP, respectively (P = 0.001). In relation to major clinical symptoms of respiratory tract infections (cough, sore throat, stuffy nose, and signs of sinusitis), AUCs varied between 0.88 and 0.93 in those patients with likely etiology (i.e., etiology is likely determined) of infection, compared to 0.63 and 0.71 for CRP, respectively, and nonsignificant AUCs for PCT. The diagnostic performance of B-HNL is superior to that of plasma CRP (P-CRP) and plasma PCT (P-PCT) in respiratory tract infections, and the activity specifically reflects bacterial challenge in the body. The rapid and accurate analysis of HNL by point-of-care technologies should be a major advancement in the diagnosis and management of respiratory infections with respect to antibiotic treatment.

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

PURPOSE

To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.

METHODS

Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.

RESULTS

Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients' perspective: the GPs considered patients' experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients' perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of "wrong decisions" and concerning the negotiation of responsibilities.

CONCLUSION

Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs' management decisions. GPs consider a holistic understanding of illness and the patients' own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs' decisions depend on the availability and reliability of other formal and informal carers, and the health care systems' organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients' social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations.

Disease Course of Lower Respiratory Tract Infection With a Bacterial Cause

PURPOSE

Bacterial pathogens are assumed to cause an illness course different from that of nonbacterial causes of acute cough, but evidence is lacking. We evaluated the disease course of lower respiratory tract infection (LRTI) with a bacterial cause in adults with acute cough.

METHODS

We conducted a secondary analysis of a multicenter European trial in which 2,061 adults with acute cough (28 days' duration or less) were recruited from primary care and randomized to amoxicillin or placebo. For this analysis only patients in the placebo group (n = 1,021) were included, reflecting the natural course of disease. Standardized microbiological and serological analyses were performed at baseline to define a bacterial cause. All patients recorded symptoms in a diary for 4 weeks. The disease course between those with and without a bacterial cause was compared by symptom severity in days 2 to 4, duration of symptoms rated moderately bad or worse, and a return consultation.

RESULTS

Of 1,021 eligible patients, 187 were excluded for missing diary records, leaving 834 patients, of whom 162 had bacterial LRTI. Patients with bacterial LRTI had worse symptoms at day 2 to 4 after the first office visit (P = .014) and returned more often for a second consultation, 27% vs 17%, than those without bacterial LRTI (P = .004). Resolution of symptoms rated moderately bad or worse did not differ (P = .375).

CONCLUSIONS

Patients with acute bacterial LRTI have a slightly worse course of disease when compared with those without an identified bacterial cause, but the relevance of this difference is not meaningful.

Predicting the presence of bacterial pathogens in the airways of primary care patients with acute cough

BACKGROUND

Bacterial testing of all patients who present with acute cough is not feasible in primary care. Furthermore, the extent to which easily obtainable clinical information predicts bacterial infection is unknown. We evaluated the diagnostic value of clinical examination and testing for C-reactive protein and procalcitonin for bacterial lower respiratory tract infection.

METHODS

Through a European diagnostic study, we recruited 3104 adults with acute cough (≤ 28 days) in primary care settings. All of the patients underwent clinical examination, measurement of C-reactive protein and procalcitonin in blood, and chest radiography. Bacterial infection was determined by conventional culture, polymerase chain reaction and serology, and positive results were defined by the presence of Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Bordetella pertussis or Legionella pneumophila. Using multivariable regression analysis, we examined the association of diagnostic variables with the presence of bacterial infection.

RESULTS

Overall, 539 patients (17%) had bacterial lower respiratory tract infection, and 38 (1%) had bacterial pneumonia. The only item with diagnostic value for lower respiratory tract infection was discoloured sputum (area under the receiver operating characteristic [ROC] curve 0.56, 95% confidence interval [CI] 0.54-0.59). Adding C-reactive protein above 30 mg/L increased the area under the ROC curve to 0.62 (95% CI 0.59-0.65). For bacterial pneumonia, comorbidity, fever and crackles on auscultation had diagnostic value (area under ROC curve 0.68, 95% CI 0.58-0.77). Adding C-reactive protein above 30 mg/L increased the area under the ROC curve to 0.79 (95% CI 0.71-0.87). Procalcitonin did not add diagnostic information for any bacterial lower respiratory tract infection, including bacterial pneumonia.

INTERPRETATION

In adults presenting with acute lower respiratory tract infection, signs, symptoms and C-reactive protein showed diagnostic value for a bacterial cause. However, the ability of these diagnostic indicators to exclude a bacterial cause was limited. Procalcitonin added no clinically relevant information.

Human neutrophil lipocalin in fMLP-activated whole blood as a diagnostic means to distinguish between acute bacterial and viral infections

The distinction between causes of acute infections is a major clinical challenge. Current biomarkers, however, are not sufficiently accurate. Human neutrophil lipocalin (HNL) in serum distinguishes acute infections with high accuracy, but in the emergency setting the assay time should be <15-20min, which excludes the use of serum samples. The aim was therefore to develop a novel rapid assay principle and test its clinical performance.

METHODS

Serum and neutrophils obtained from 84 infected and 20 healthy subjects were used in the experimental study. 725 subjects (144 healthy controls and 581 patients with signs and symptoms of acute infections) were included in the clinical study. HNL was measured in EDTA-plasma by ELISA or in heparinized whole blood after fMLP activation by a prototype point-of-care assay.

RESULTS

Increased release of HNL from neutrophils after activation with fMLP was seen already after 5 min incubation. The release of HNL from purified neutrophils after 15 min incubation with fMLP was significantly correlated to the HNL concentrations in serum obtained from the same patient (r = 0.74, p < 0.001). In the distinction between healthy controls and patients with bacterial infections, the areas under the ROC-curves were 0.95 (95% CI 0.91-0.97) and 0.88 (95% CI 0.84-0.91) for HNL in fMLP-activated whole blood and EDTA-plasma, respectively, (p < 0.001) and in the distinction between bacterial and viral infections 0.91 (95% CI 0.86-0.95) and 0.76 (95% CI 0.70-0.81), respectively (p < 0.001).

CONCLUSION

The clinical performance of HNL in fMLP-activated whole blood was superior to HNL in EDTA-plasma and similar to HNL in serum. The procedure can be adopted for point-of-care testing with response times of <15 min.

Narrative review of primary care point-of-care testing (POCT) and antibacterial use in respiratory tract infection (RTI)

Antimicrobial resistance is a global problem and is being addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) and procalcitonin, measurements to guide antibacterial prescribing in adult patients presenting to GP practices with symptoms of respiratory tract infection (RTI). Studies that were included were randomised controlled trials, controlled before and after studies, cohort studies and economic evaluations. Many studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces antibiotic prescribing by 23.3% to 36.16%. Procalcitonin is not currently available as a point-of-care testing (POCT), but has shown value for patients with RTI admitted to hospital. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. CRP POCT can better target antibacterial prescribing by GPs and contribute to national antimicrobial resistance strategies. Health services need to develop ways to ensure funding is transferred in order for POCT to be implemented.

Suspected community-acquired pneumonia in an ambulatory setting (CAPA): a French prospective observational cohort study in general practice

Background:

Few studies have addressed the pragmatic management of ambulatory patients with suspected community-acquired pneumonia (CAP) using a precise description of the disease with or without chest X-ray (X-ray) evidence.

Aims:

To describe the characteristics, clinical findings, additional investigations and disease progression in patients with suspected CAP managed by French General Practitioners (GPs).

Methods:

The patients included were older than 18 years, with signs or symptoms suggestive of CAP associated with recent-onset unilateral crackles on auscultation or a new opacity on X-ray. They were followed for up to 6 weeks. Descriptive analyses of all patients and according to their management with X-rays were carried out.

Results:

From September 2011 to July 2012, 886 patients have been consulted by 267 GPs. Among them, 278 (31%) were older than 65 years and 337 (38%) were at increased risk for invasive pneumococcal disease. At presentation, the three most common symptoms, cough (94%), fever (93%), and weakness or myalgia (81%), were all observed in 70% of patients. Unilateral crackles were observed in 77% of patients. Among patients with positive radiography (64%), 36% had no unilateral crackles. A null CRB-65 score was obtained in 62% of patients. Most patients (94%) initially received antibiotics and experienced uncomplicated disease progression regardless of their management with X-rays. Finally, 7% of patients were hospitalised and 0.3% died.

Conclusions:

Most patients consulting GPs for suspected CAP had the three following most common symptoms: cough, fever, and weakness or myalgia. More than a third of them were at increased risk for invasive pneumococcal disease. With or without X-rays, most patients received antibiotics and experienced uncomplicated disease progression.

Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care

Background Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. Unnecessary antibiotic use will, in many cases, not be beneficial to the patients' recovery and expose them to potential side effects. Furthermore, as a causal link exists between antibiotic use and antibiotic resistance, reducing unnecessary antibiotic use is a key factor in controlling this important problem. Antibiotic resistance puts increasing burdens on healthcare services and renders patients at risk of future ineffective treatments, in turn increasing morbidity and mortality from infectious diseases. One strategy aiming to reduce antibiotic use in primary care is the guidance of antibiotic treatment by use of a point-of-care biomarker. A point-of-care biomarker of infection forms part of the acute phase response to acute tissue injury regardless of the aetiology (infection, trauma and inflammation) and may in the correct clinical context be used as a surrogate marker of infection,possibly assisting the doctor in the clinical management of ARIs.Objectives To assess the benefits and harms of point-of-care biomarker tests of infection to guide antibiotic treatment in patients presenting with symptoms of acute respiratory infections in primary care settings regardless of age.Search methods We searched CENTRAL (2013, Issue 12), MEDLINE (1946 to January 2014), EMBASE (2010 to January 2014), CINAHL (1981 to January 2014), Web of Science (1955 to January 2014) and LILACS (1982 to January 2014).Selection criteria We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared use of point-of-care biomarkers with standard of care. We included trials that randomised individual patients as well as trials that randomised clusters of patients(cluster-RCTs).Two review authors independently extracted data on the following outcomes: i) impact on antibiotic use; ii) duration of and recovery from infection; iii) complications including the number of re-consultations, hospitalisations and mortality; iv) patient satisfaction. We assessed the risk of bias of all included trials and applied GRADE. We used random-effects meta-analyses when feasible. We further analysed results with a high level of heterogeneity in pre-specified subgroups of individually and cluster-RCTs.Main results The only point-of-care biomarker of infection currently available to primary care identified in this review was C-reactive protein. We included six trials (3284 participants; 139 children) that evaluated a C-reactive protein point-of-care test. The available information was from trials with a low to moderate risk of bias that address the main objectives of this review.Overall a reduction in the use of antibiotic treatments was found in the C-reactive protein group (631/1685) versus standard of care(785/1599). However, the high level of heterogeneity and the statistically significant test for subgroup differences between the three RCTs and three cluster-RCTs suggest that the results of the meta-analysis on antibiotic use should be interpreted with caution and the pooled effect estimate (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92; I2 statistic = 68%) may not be meaningful.The observed heterogeneity disappeared in our pre planned subgroup analysis based on study design: RR 0.90, 95% CI 0.80 to 1.02; I2 statistic = 5% for RCTs and RR 0.68, 95% CI 0.61 to 0.75; I2 statistic = 0% for cluster-RCTs, suggesting that this was the cause of the observed heterogeneity.There was no difference between using a C-reactive protein point-of-care test and standard care in clinical recovery (defined as at least substantial improvement at day 7 and 28 or need for re-consultations day 28). However, we noted an increase in hospitalisations in the C-reactive protein group in one study, but this was based on few events and may be a chance finding. No deaths were reported in any of the included studies.We classified the quality of the evidence as moderate according to GRADE due to imprecision of the main effect estimate.Authors' conclusions A point-of-care biomarker (e.g. C-reactive protein) to guide antibiotic treatment of ARIs in primary care can reduce antibiotic use,although the degree of reduction remains uncertain. Used as an adjunct to a doctor's clinical examination this reduction in antibiotic use did not affect patient-reported outcomes, including recovery from and duration of illness.However, a possible increase in hospitalisations is of concern. A more precise effect estimate is needed to assess the costs of the intervention and compare the use of a point-of-care biomarker to other antibiotic-saving strategies.

Laboratory features of common causes of fever in returned travelers

BACKGROUND

There can be considerable overlap in the clinical presentation and laboratory features of dengue, malaria, and enteric fever, three important causes of fever in returned travelers. Routine laboratory tests including full blood examination (FBE), liver function tests (LFTs), and C-reactive protein (CRP) are frequently ordered on febrile patients, and may help differentiate between these possible diagnoses.

METHODS

Adult travelers returning to Australia who presented to the Royal Melbourne Hospital with confirmed diagnosis of dengue, malaria, or enteric fever between January 1, 2000 and March 1, 2013 were included in this retrospective study. Laboratory results for routine initial investigations performed within the first 2 days were extracted and analyzed.

RESULTS

There were 304 presentations including 58 with dengue fever, 187 with malaria, and 59 with enteric fever, comprising 56% of all returned travelers with a febrile systemic illness during the study period. Significant findings included 9-fold and 21-fold odds of a normal CRP in dengue compared with malaria and enteric fever, respectively. The odds of an abnormally low white cell count (WCC) were also significantly greater in dengue versus malaria or enteric fever. Approximately one third of dengue presentations and almost half of the malaria presentations had platelet counts <100 × 10(9) /L. A normal CRP with leukopenia and/or thrombocytopenia occurred in 21% to 30% of dengue presentations, but not in malaria or enteric fever presentations.

CONCLUSIONS

There is a wide differential diagnosis for imported fever, but the non-specific findings of a normal CRP with a low WCC and/or low platelet count may provide useful information in addition to clinical clues to suggest dengue over malaria or enteric fever. Further systematic prospective studies among travelers could help define the potential clinical utility of these results in assisting the clinician when deciding for or against commencement of empiric antimicrobial therapy while awaiting confirmatory tests.

Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study

OBJECTIVES

To quantify the diagnostic accuracy of selected inflammatory markers in addition to symptoms and signs for predicting pneumonia and to derive a diagnostic tool.

DESIGN

Diagnostic study performed between 2007 and 2010. Participants had their history taken, underwent physical examination and measurement of C reactive protein (CRP) and procalcitonin in venous blood on the day they first consulted, and underwent chest radiography within seven days.

SETTING

Primary care centres in 12 European countries.

PARTICIPANTS

Adults presenting with acute cough.

MAIN OUTCOME MEASURES

Pneumonia as determined by radiologists, who were blind to all other information when they judged chest radiographs.

RESULTS

Of 3106 eligible patients, 286 were excluded because of missing or inadequate chest radiographs, leaving 2820 patients (mean age 50, 40% men) of whom 140 (5%) had pneumonia. Re-assessment of a subset of 1675 chest radiographs showed agreement in 94% (κ 0.45, 95% confidence interval 0.36 to 0.54). Six published "symptoms and signs models" varied in their discrimination (area under receiver operating characteristics curve (ROC) ranged from 0.55 (95% confidence interval 0.50 to 0.61) to 0.71 (0.66 to 0.76)). The optimal combination of clinical prediction items derived from our patients included absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever, with an ROC area of 0.70 (0.65 to 0.75). Addition of CRP at the optimal cut off of >30 mg/L increased the ROC area to 0.77 (0.73 to 0.81) and improved the diagnostic classification (net reclassification improvement 28%). In the 1556 patients classified according to symptoms, signs, and CRP >30 mg/L as "low risk" (<2.5%) for pneumonia, the prevalence of pneumonia was 2%. In the 132 patients classified as "high risk" (>20%), the prevalence of pneumonia was 31%. The positive likelihood ratio of low, intermediate, and high risk for pneumonia was 0.4, 1.2, and 8.6 respectively. Measurement of procalcitonin added no relevant additional diagnostic information. A simplified diagnostic score based on symptoms, signs, and CRP >30 mg/L resulted in proportions of pneumonia of 0.7%, 3.8%, and 18.2% in the low, intermediate, and high risk group respectively.

CONCLUSIONS

A clinical rule based on symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough performed best in patients with mild or severe clinical presentation. Addition of CRP concentration at the optimal cut off of >30 mg/L improved diagnostic information, but measurement of procalcitonin concentration did not add clinically relevant information in this group.

Variation in family physicians' recording of auscultation abnormalities in patients with acute cough is not explained by case mix. A study from 12 European networks

BACKGROUND

Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology.

OBJECTIVES

To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms.

METHODS

Clinicians recorded whether 'diminished vesicular breathing', 'wheezes', 'crackles' and 'rhonchi' were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients' gender, age, comorbidities, smoking status and symptoms.

RESULTS

2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3-30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi.

CONCLUSION

There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.

Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial

PURPOSE

The purpose of the study was to assess the long-term effect of family physicians' use of C-reactive protein (CRP) point-of-care testing and/or physician training in enhanced communication skills on office visit rates and antibiotic prescriptions for patients with respiratory tract infections.

METHODS

We conducted a 3.5-year follow-up of a pragmatic, factorial, cluster-randomized controlled trial; 379 patients (20 family practices in the Netherlands) who visited their family physician for acute cough were enrolled in the trial and had follow-up data available (88% of original trial cohort). Main outcome measures were the average number of episodes of respiratory tract infections for which patients visited their family physician per patient per year (PPPY), and the percentage of the episodes for which patients were treated with antibiotics during follow-up.

RESULTS

The mean number of episodes of respiratory tract infections during follow-up was 0.40 PPPY in the CRP test group and 0.56 PPPY in the no CRP test group (P = .12). In the communication skills training group, there was a mean of 0.36 PPPY episodes of respiratory tract infections, and in the no training group the mean was 0.57 PPPY (P = .09). During follow-up 30.7% of all episodes of respiratory tract infection were treated with antibiotics in the CRP test group compared with 35.7% in the no test group (P = .36). Family physicians trained in communication skills treated 26.3% of all episodes of respiratory tract infection with antibiotics compared with 39.1% treated by family physicians without training in communication skills (P = .02)

CONCLUSIONS

Family physicians' use of CRP point-of-care testing and/or training in enhanced communication skills did not significantly affect office visit rates related to respiratory tract infections. Patients who saw a family physician trained in enhanced communication skills were prescribed significantly fewer antibiotics during episodes of respiratory tract infection in the subsequent 3.5 years.

Evaluating the evidence for the implementation of C-reactive protein measurement in adult patients with suspected lower respiratory tract infection in primary care: a systematic review

BACKGROUND

Excessive prescription of antibiotics in patients with lower respiratory tract infection (LRTI) is common in primary care and might be reduced by rapid point-of-care (POC) C-reactive protein (CRP) testing. However, the exact benefits of this test are unclear.

OBJECTIVE

To review the available evidence for the role of POC CRP measurement in (i) guiding antibiotic prescription, (ii) predicting aetiology, (iii) prognosis and (iv) diagnosis (pneumonia) in LRTI patients.

METHODS

For each research question, studies were retrieved through an electronic literature search in Medline, Embase and the Cochrane Library using synonyms for CRP and LRTI combined with different relevant subheadings. Study quality was assessed using validated instruments and predefined outcome measures were extracted from each study.

RESULTS

The search yielded 13 articles, each answering one or more questions; one was excluded by insufficient internal validity. (i) One of four studies showed a significant reduction in the antibiotic prescriptions when applying POC CRP measurement [relative risk (RR) 0.6, 95% confidence interval (CI) 0.5-0.7]. (ii) Three studies on aetiology demonstrated that an elevated CRP was associated with bacterial [odds ratio (OR) 2.46-4.8] and one with viral (OR 2.7) aetiology. (iii) Results on the prognostic value were contradictory, providing evidence for faster symptom resolution (RR 1.16, 95% CI 1.1-1.3), higher mortality rate (RR 2.5, 95% CI 1.2-5.1) and no difference in outcome in patients with high CRP levels. (iv) Four studies showed that CRP had limited value as a single predictor of pneumonia. When combined with clinical assessment, its value increased according to two of these studies (receiver operating characteristic area from 0.7 to 0.9). However, methodological flaws and/or wide CIs limit the generalizability of findings in all studies.

CONCLUSION

The evidence for the benefits of POC CRP measurement in LRTI patients in primary care is limited, contradictory and does not support its use to guide treatment decisions yet.

Clinical influences on antibiotic prescribing decisions for lower respiratory tract infection: a nine country qualitative study of variation in care

OBJECTIVES

There is variation in antibiotic prescribing for lower respiratory tract infections (LRTI) in primary care that does not benefit patients. This study aims to investigate clinicians' accounts of clinical influences on antibiotic prescribing decisions for LRTI to better understand variation and identify opportunities for improvement.

DESIGN

Multi country qualitative interview study. Semi-structured interviews using open-ended questions and a patient scenario. Data were subjected to five-stage analytic framework approach (familiarisation, developing a thematic framework from the interview questions and emerging themes, indexing, charting and mapping to search for interpretations), with interviewers commenting on preliminary reports.

SETTING

Primary care.

PARTICIPANTS

80 primary care clinicians randomly selected from primary care research networks based in nine European cities.

RESULTS

Clinicians reported four main individual clinical factors that guided their antibiotic prescribing decision: auscultation, fever, discoloured sputum and breathlessness. These were considered alongside a general impression of the patient derived from building a picture of the illness course, using intuition and familiarity with the patient. Comorbidity and older age were considered main risk factors for poor outcomes. Clinical factors were similar across networks, apart from C reactive protein near patient testing in Tromsø. Clinicians developed ways to handle diagnostic and management uncertainty through their own clinical routines.

CONCLUSIONS

Clinicians emphasised the importance of auscultation, fever, discoloured sputum and breathlessness, general impression of the illness course, familiarity with the patient, comorbidity, and age in informing their antibiotic prescribing decisions for LRTI. As some of these factors may be overemphasised given the evolving evidence base, greater standardisation of assessment and integration of findings may help reduce unhelpful variation in management. Non-clinical influences will also need to be addressed.

Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study

BACKGROUND

Antibiotics are widely believed to be overused and misused. Approximately 80% of all prescriptions for antibiotics are written by GPs. There are many external factors that influence a GP's decision to prescribe, including patient pressure. Access to primary care services operates on a two-tier system in the Republic of Ireland: General Medical Service (GMS) card holders have free access to GPs and medications; and non-card holders (private patients) must pay a non-subsidised fee to visit their GP.

AIM

To ascertain whether there was a difference in antibiotic prescribing practice between those who pay a fee for their GP consultation and those who attend free of charge.

DESIGN AND SETTING

Cohort study in Irish general practice.

METHOD

All GPs attending continuing medical education (CME) groups nationwide were invited to participate from October 2008 until April 2010. GPs gathered data on 100 consecutive consultations including diagnosis and patient characteristics.

RESULTS

Data were collected from 171 GPs (distributed throughout Ireland), which resulted in 16 899 consultations. Antibiotics were prescribed at 3407 (20.16%) consultations. Nearly half of the prescriptions were for GMS card holders (n = 1669; 48.99%) and 1526 (44.79%) were for private patients; for 212 (6.22%) the payment status of the patient was unknown. Private patients were more likely to receive a prescription for antibiotics (odds ratio 1.23, 95% confidence interval = 1.14 to 1.33).

CONCLUSION

These results demonstrate that a GP's decision to provide a prescription for antibiotics may be influenced by whether or not the patient pays for their consultation at the GP interface. Private patients are more likely than GMS card holders to receive a prescription for antibiotics.

Influence of CRP testing and clinical findings on antibiotic prescribing in adults presenting with acute cough in primary care

OBJECTIVE

Respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The value of clinical findings in lower respiratory tract infection (LRTI) is known to be overrated. This study aimed to determine the independent influence of a point of care test (POCT) for C-reactive protein (CRP) on the prescription of antibiotics in patients with acute cough or symptoms suggestive of LRTI, and how symptoms and chest findings influence the decision to prescribe when the test is and is not used.

DESIGN

Prospective observational study of presentation and management of acute cough/LRTI in adults.

SETTING

Primary care research networks in Norway, Sweden, and Wales.

SUBJECTS

Adult patients contacting their GP with symptoms of acute cough/LRTI.

MAIN OUTCOME MEASURES

Predictors of antibiotic prescribing were evaluated in those tested and those not tested with a POCT for CRP using logistic regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 803 patients were recruited in the three networks. Among the 372 patients tested with a POCT for CRP, the CRP value was the strongest independent predictor of antibiotic prescribing, with an odds ratio (OR) of CRP ≥ 50 mg/L of 98.1. Crackles on auscultation and a patient preference for antibiotics perceived by the GP were the strongest predictors of antibiotic prescribing when the CRP test was not used.

CONCLUSIONS

The CRP result is a major influence in the decision whether or not to prescribe antibiotics for acute cough. Clinicians attach less weight to discoloured sputum and abnormal lung sounds when a CRP value is available. CRP testing could prevent undue reliance on clinical features that poorly predict benefit from antibiotic treatment.

Point-of-care C-reactive protein testing and antibiotic prescribing for respiratory tract infections: a randomized controlled trial

PURPOSE

Antibiotics are only beneficial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) point-of-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis.

METHODS

We conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery.

RESULTS

Patients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confidence interval [CI], 0.56-0.98). This difference remained significant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were filled only in a minority of cases (23% vs 72% in control group, P < .001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03).

CONCLUSIONS

CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery.

C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm

BACKGROUND

Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness.

OBJECTIVE

To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults.

METHODS

A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level.

RESULTS

There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29-45%] vs. 31% [95% CI 23-39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43-61%] vs. 48% [95% CI 39-57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7-33%] vs. 50% [95% CI 32-68%], respectively; p = 0.01).

CONCLUSIONS

Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness.

Limited value of chest radiography in predicting aetiology of lower respiratory tract infection in general practice

BACKGROUND

In patients with lower respiratory tract infection (LRTI), changes on chest radiography are rare but poorly characterised, especially in general practice.

AIM

To describe the range of findings on chest radiographs and the associations between these findings and the aetiology of LRTI.

DESIGN OF STUDY

A prospective observational study.

SETTING

General practices in the Leiden region, The Netherlands.

METHOD

Adult patients with a defined LRTI were included. Standard medical history and physical examination were performed. Sputum, blood, and throat swabs were collected for diagnostic tests. Chest X-ray findings were assessed in relation to the aetiology.

RESULTS

An abnormality on the chest X-ray was observed in 72 (55%) patients. Forty-five patients (35%) had changes due to infection, and 26 (20%) due to pneumonia. Pathogens were detected in 84 patients (33 single bacterial, 43 single viral, and 8 dual). Twelve (29%) patients with a bacterial infection (including dual infections) compared to four (9%) patients with viral infection had pneumonia on the chest X-ray (odds ratio [OR] = 4.0; 95% confidence interval [CI] = 1.2 to 13.8). Using the presence of pneumonia on chest X-ray as a test to predict a bacterial infection, the positive predictive value and the negative predictive value were 75% (CI = 48 to 93%) and 57% (CI = 45 to 69%), respectively.

CONCLUSION

Pneumonia on the chest X-ray was found more frequently in patients with a bacterial infection than in patients with a viral infection. However, the sensitivity and the specificity are such that pneumonia on the chest X-ray is not a reliable test to discriminate between bacterial and non-bacterial LRTI in the general practice setting.

Vermindering van diagnostiek en overbehandeling bij RS-virus-bronchiolitis na geprotocolleerde behandeling

Doel: Evalueren of invoering van een protocol ’Diagnostiek en behandeling van RS-virus-bronchiolitis’ leidt tot minder thoraxfoto’s, minder C-reactieve proteïne (CRP-) en leukocytenbepalingen en minder antibioticavoorschriften bij opgenomen kinderen met respiratoir syncytieel (RS-)bronchiolitis

Opzet: Retrospectieve ‘vóór-ná’-cohortstudie.

Plaats: Canisius-Wilhelmina Ziekenhuis, Nijmegen

Patiënten: Opgenomen kinderen met bewezen RS-virusinfectie

Methoden: Het protocol, met duidelijke restricties voor wat betreft het maken van een thoraxfoto en het bepalen van CRP en leukocyten, werd in februari 2003 ingevoerd. Data van kinderen met RSvirusinfectie opgenomen in de periode 1997 t/m 1999 (cohort A) werden vergeleken met die van kinderen opgenomen van 2003 t/m april 2006 (cohort B).

Resultaten: Cohort A omvatte 155 kinderen en cohort B 170. Na invoering van het protocol nam het aantal CRP- en leukocytenbepalingen af met respectievelijk 49,0% en 48,2% (beide p<0,001) en het aantal thoraxfoto’s met 30,3% (p=0,020). Antibioticatoediening nam af met 55% (p<0,001). De kans op het krijgen van antibiotica nam significant toe zodra een thoraxfoto werd gemaakt (OR=5,2), een CRP-bepaling werd gedaan (OR=5,4) of een leukocytenbepaling werd verricht (OR=4,2). De mediane opnameduur nam na invoering van het protocol significant af van 8,0 naar 6,0 dagen (p<0,001; range 1-13 dagen en 2-23 dagen, respectievelijk). Het verrichten van CRP- en leukocytenbepalingen, het maken van een thoraxfoto of antibioticatoediening hadden geen significante invloed op de opnameduur.

Conclusie: Invoering van het protocol leidde tot significante afname van het aantal thoraxfoto’s, CRP- en leukocytenbepalingen en antibioticavoorschriften. Onze gegevens ondersteunen een restrictief beleid met betrekking tot het verrichten van thoraxfoto’s, CRP- en leukocytenbepalingen bij in het ziekenhuis opgenomen kinderen met RS-virus-bronchiolitis

Community-Acquired Pneumonia—Back to Basics

Lower respiratory tract infections are among the most common infectious diseases worldwide and are caused by the inflammation and consolidation of lung tissue due to an infectious agent.¹ The clinical criteria for the diagnosis include chest pain, cough, auscultatory findings such as rales or evidence of pulmonary consolidation, fever, or leukocytosis.

The necessary shift from diagnostic to prognostic research

Background

Do doctors really need to establish an etiological diagnosis each time a patient presents? Or might it often be more effective to treat simply on the basis of symptoms and signs alone, relying on research and on our experience of outcomes for patients who presented in similar ways in the past?

Discussion

At a time of increase health care costs especially in pharmaceuticals and expensive diagnostic tests, this article uses examples from recent research to address this question. Our examples come from general practice, because that is where doctors frequently see patients presenting with a yet undifferentiated disease which is consequently difficult to diagnose. The examples include respiratory tract infections, low back pain and shoulder pain. Finally we discuss the 'something is wrong' feeling.

Summary

We conclude that, in addition to diagnostic research, a renewed focus on prognostic research is needed.

Overprescribing of antibiotics to children in rural Vietnam

100 children (aged 1-6 y), who received an antibiotic prescription after health examination in the Bavi health care system (79 children at a district hospital, 21 at a community health centre) were analysed regarding antibiotics prescribed in relation to serum C-reactive protein (CRP). A control group consisted of 35 healthy children. Children who had been treated with antibiotics within 1 week prior to the study were excluded in the community health centre and control groups. Capillary blood samples were collected and the serum CRP concentration was analysed. A questionnaire interview with the carers was performed. Elevated CRP concentrations (>10 mg/l) were detected in 17 (17%) of the study population, and only 2 had a CRP level above 25 mg/l, one 36 mg/l and the other 140 mg/l. In the control group, none of the children had elevated CRP. The most common diagnoses were acute respiratory tract infection (ARI, 55%), asthma (7%), tonsillitis (4%), and diarrhoea (4%). The average number of drugs per patient was 3.1, and 77% received vitamins and 15% corticosteroids in combination with antibiotics. A majority of children who received an antibiotic prescription based on clinical examination did not have an elevated CRP and overprescribing of antibiotics was thus indicated.

Treating patients not diagnoses: challenging assumptions underlying the investigation and management of LRTI in general practice

OBJECTIVES

Many clinicians treat patients with a lower respiratory tract infection (LRTI) due to bacterial infection with antibiotics, and regard antibiotic treatment as obligatory for patients with radiographic evidence of pneumonia. The necessity of antibiotic treatment is largely unknown and rarely challenged.

PATIENTS AND METHODS

Twenty-five general practitioners (GPs) recorded clinical information on 247 adult patients presenting with LRTI. Standard microbiological, susceptibility and serological analysis, and chest radiography was performed for all patients. At 28 days after entry into the study, the GPs took a history and conducted a physical examination again and decided whether or not the patient was fully recovered.

RESULTS

Thirty of 63 patients with cultured pathogenic bacteria were either not treated with antibiotics, or treated with an antibiotic to which the cultured bacterium was non-susceptible. All but one recovered spontaneously, although it took more than 28 days for two patients. The other patient recovered with an additional course of antibiotics. Five patients from this cohort with radiological evidence of pneumonia fully recovered without antibiotic treatment.

CONCLUSIONS

Not all patients with bacterial LRTI and/or pneumonia require antibiotic treatment in order to recover. Managing the patient rather than treating a diagnosis appears safe and effective in general practice.