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Van Hoovels L, Massa B, Stavelin A, De Meyer H, De Schrijver P, Van Laethem V, Barglazan D, Gruson D, Hopstaken R, Peeters B, Van Hoof V, Verdonck A, Verbakel JY. Analytical performance and user-friendliness of four commercially available point-of-care devices for C-reactive protein. Clin Chim Acta 2024; 560:119737. [PMID: 38768699 DOI: 10.1016/j.cca.2024.119737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
INTRODUCTION Proper implementation of Point-of-Care testing (POCT) for C-reactive protein (CRP) in primary care can decrease the inappropriate use of antibiotics, thereby tackling the problem of growing antimicrobial resistance. OBJECTIVE The analytical performance and user-friendliness of four POCT-CRP assays were evaluated: QuikRead go easy, LumiraDx, cobas b 101 and Afinion 2. MATERIALS AND METHODS Imprecision was evaluated using plasma pools in addition to manufacturer-specific control material. Trueness was assessed by verification of traceability to ERM-DA474/IFCC in parallel to method comparison towards the central laboratory CRP method (cobas c 503) using i) retrospectively selected plasma samples (n = 100) and ii) prospectively collected capillary whole blood samples (n = 50). User-friendliness was examined using a questionnaire. RESULTS Between-day imprecision on plasma pools varied from 4.5 % (LumiraDx) to 11.5 % (QuikRead). Traceability verification revealed no significant difference between cobas c 503 CRP results and the ERM-DA474/IFCC certified value. cobas b 101 and Afinion achieved the best agreement with the central laboratory method. LumiraDx and QuikRead revealed a negative mean difference, with LumiraDx violating the criterion of > 95 % of POCT-CRP-results within ± 20 % of the comparison method. Regarding user-friendliness, Afinion obtained the highest Likert-scores. CONCLUSION The analytical performance and user-friendliness of POCT-CRP devices varies among manufacturers, emphasizing the need for quality assurance supervised by a central laboratory.
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Affiliation(s)
- Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Hospital Aalst, Aalst, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
| | - Bo Massa
- Department of Laboratory Medicine, OLV Hospital Aalst, Aalst, Belgium; Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
| | - Anne Stavelin
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Helene De Meyer
- Department of Laboratory Medicine, OLV Hospital Aalst, Aalst, Belgium
| | | | | | - Dragos Barglazan
- Laboratoire Hospitalier Universitaire de Bruxelles, Universitair Laboratorium Brussel (LHUB-ULB), Brussels, Belgium
| | - Damien Gruson
- Department of Medical Biochemistry, Clinique Saint-Luc, UCLouvain, Woluwe-Saint-Lambert, Belgium
| | | | - Bart Peeters
- Department of Laboratory Medicine, Heilig Hart Hospital Lier, Lier, Belgium
| | - Viviane Van Hoof
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Ann Verdonck
- Department of Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Academisch Centrum Huisartsgeneeskunde, KU Leuven, Leuven, Belgium; NIHR Community Healthcare Medtech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Cassidy CA, Kabugho L, Kibaba G, Lin B, Hollingsworth B, Baguma E, Juliano JJ, Mulogo EM, Boyce RM, Ciccone EJ. Comparison of commercially available, rapid, point-of-care C-reactive protein assays among children with febrile illness in southwestern Uganda. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002727. [PMID: 38241274 PMCID: PMC10798459 DOI: 10.1371/journal.pgph.0002727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/21/2023] [Indexed: 01/21/2024]
Abstract
In Uganda, children with febrile illness are often treated with antibiotics even though most have self-limiting, likely viral, infections. C-reactive protein (CRP) measurement can help identify those who are more likely to have a bacterial infection and therefore need antibiotic treatment. Implementation of a CRP rapid diagnostic test (RDT) at the point-of-care in resource-constrained settings with minimal laboratory infrastructure could reduce unnecessary antibiotic use. In this study, we evaluated the performance of three semi-quantitative CRP RDTs (Actim, BTNX, Duo) against a reference CRP assay requiring an electrically powered analyzer (Afinion). While both tests demonstrated substantial agreement with Afinion, Actim had slightly higher agreement than BTNX. The sensitivity was higher for the BTNX test, whereas the Actim test had a higher specificity, at cut-offs of 40 mg/L and 80 mg/L. At a cut-off of 20 mg/L, Duo demonstrated substantial agreement with the Afinion test as well. Our results demonstrate the reliability of CRP RDTs when compared to a reference standard. CRP RDTs without the need for a laboratory-based analyzer are promising tools for optimizing antibiotic use in low-resource settings.
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Affiliation(s)
- Caitlin A. Cassidy
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Lydiah Kabugho
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Georget Kibaba
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bradley Lin
- Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Brandon Hollingsworth
- Department of Entomology, Cornell University, Ithaca, New York, United States of America
| | - Emmanuel Baguma
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jonathan J. Juliano
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Edgar M. Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ross M. Boyce
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Emily J. Ciccone
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Johannsen B, Baumgartner D, Karpíšek M, Stejskal D, Boillat-Blanco N, Knüsli J, Panning M, Paust N, Zengerle R, Mitsakakis K. Patient Stratification for Antibiotic Prescriptions Based on the Bound-Free Phase Detection Immunoassay of C-Reactive Protein in Serum Samples. BIOSENSORS 2023; 13:1009. [PMID: 38131769 PMCID: PMC10741775 DOI: 10.3390/bios13121009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
C-reactive protein is a well-studied host response biomarker, whose diagnostic performance depends on its accurate classification into concentration zones defined by clinical scenario-specific cutoff values. We validated a newly developed, bead-based, bound-free phase detection immunoassay (BFPD-IA) versus a commercial CE-IVD enzyme-linked immunosorbent assay (ELISA) kit and a commercial CE-IVD immunoturbidimetric assay (ITA) kit. The latter was performed on a fully automated DPC Konelab 60i clinical analyzer used in routine diagnosis. We classified 53 samples into concentration zones derived from four different sets of cutoff values that are related to antibiotic prescription scenarios in the case of respiratory tract infections. The agreements between the methods were ELISA/ITA at 87.7%, ELISA/BFPD-IA at 87.3%, and ITA/-BFPD-IA at 93.9%, reaching 98-99% in all cases when considering the calculated relative combined uncertainty of the single measurement of each sample. In a subgroup of 37 samples, which were analyzed for absolute concentration quantification, the scatter plot slopes' correlations were as follows: ELISA/ITA 1.15, R2 = 0.97; BFPD-IA/ELISA 1.12, R2 = 0.95; BFPD-IA/ITA 0.95, R2 = 0.93. These very good performances and the agreement between BFPD-IA and ITA (routine diagnostic), combined with BFPD-IA's functional advantages over ITA (and ELISA)-such as quick time to result (~20 min), reduced consumed reagents (only one assay buffer and no washing), few and easy steps, and compatibility with nucleic-acid-amplification instruments-render it a potential approach for a reliable, cost-efficient, evidence-based point-of-care diagnostic test for guiding antibiotic prescriptions.
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Affiliation(s)
- Benita Johannsen
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | | | - Michal Karpíšek
- BioVendor-Laboratorní Medicína a.s., Research & Diagnostic Products Division, Karasek 1767/1, Reckovice, 62100 Brno, Czech Republic
- Faculty of Pharmacy, Masaryk University, Palackeho trida 1946/1, 61242 Brno, Czech Republic
| | - David Stejskal
- Department of Biomedical Sciences, Faculty of Medicine, University of Ostrava, Syllabova 19, 70300 Ostrava, Czech Republic
- Institute of Laboratory Diagnostics, University Hospital Ostrava, 17. listopadu 1790/5, 70800 Ostrava, Czech Republic
| | - Noémie Boillat-Blanco
- Service of Infectious Diseases, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - José Knüsli
- Service of Infectious Diseases, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Marcus Panning
- Institute of Virology, Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Hermann-Herder-Strasse 11, 79104 Freiburg, Germany
| | - Nils Paust
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Laboratory for MEMS Applications, IMTEK–Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Roland Zengerle
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Laboratory for MEMS Applications, IMTEK–Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
| | - Konstantinos Mitsakakis
- Hahn-Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
- Laboratory for MEMS Applications, IMTEK–Department of Microsystems Engineering, University of Freiburg, Georges-Koehler-Allee 103, 79110 Freiburg, Germany
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Calarco S, Fernandez-Carballo BL, Keller T, Weber S, Jakobi M, Marsall P, Schneiderhan-Marra N, Dittrich S. Analytical performance of 17 commercially available point-of-care tests for CRP to support patient management at lower levels of the health system. PLoS One 2023; 18:e0267516. [PMID: 36662693 PMCID: PMC9858008 DOI: 10.1371/journal.pone.0267516] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023] Open
Abstract
Accurate and precise point-of-care (POC) testing for C-reactive protein (CRP) can help support healthcare providers in the clinical management of patients. Here, we compared the analytical performance of 17 commercially available POC CRP tests to enable more decentralized use of the tool. The following CRP tests were evaluated. Eight quantitative tests: QuikRead go (Aidian), INCLIX (Sugentech), Spinit (Biosurfit), LS4000 (Lansionbio), GS 1200 (Gensure Biotech), Standard F200 (SD Biosensor), Epithod 616 (DxGen), IFP-3000 (Xincheng Biological); and nine semi-quantitative tests: Actim CRP (ACTIM), NADAL Dipstick (nal von minden), NADAL cassette (nal von minden), ALLTEST Dipstick (Hangzhou Alltest Biotech), ALLTEST Cassette cut-off 10-40-80 (Hangzhou Alltest Biotech), ALLTEST Cassette cut-off 10-30 (Hangzhou Alltest Biotech), Biotest (Hangzhou Biotest Biotech), BTNX Quad Line (BTNX), BTNX Tri Line (BTNX). Stored samples (n = 660) had previously been tested for CRP using Cobas 8000 Modular analyzer (Roche Diagnostics International AG, Rotkreuz, Switzerland (reference standards). CRP values represented the clinically relevant range (10-100 mg/L) and were grouped into four categories (<10 mg/L, 10-40 mg/L or 10-30 mg/L, 40-80 mg/L or 30-80 mg/L, and > 80mg/L) for majority of the semi-quantitative tests. Among the eight quantitative POC tests evaluated, QuikRead go and Spinit exhibited better agreement with the reference method, showing slopes of 0.963 and 0.921, respectively. Semi-quantitative tests with the four categories showed a poor percentage agreement for the intermediate categories and higher percentage agreement for the lower and upper limit categories. Analytical performance varied considerably for the semi-quantitative tests, especially among the different categories of CRP values. Our findings suggest that quantitative tests might represent the best choice for a variety of use cases, as they can be used across a broad range of CRP categories.
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Affiliation(s)
| | | | | | | | - Meike Jakobi
- NMI Natural and Medical Sciences Institute at the University of Tübingen, Reutlingen, Germany
| | - Patrick Marsall
- NMI Natural and Medical Sciences Institute at the University of Tübingen, Reutlingen, Germany
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Bonko MDA, Karama I, Kiemde F, Lompo P, Garba Z, Yougbaré S, Mens PF, Tinto H, Tahita MC, Schallig HDFH. Could combined rapid diagnostic testing for malaria and c-reactive protein be helpful for the diagnosis and management of febrile illnesses in children under-5 years of age in rural Burkina Faso? BMC Infect Dis 2022; 22:952. [PMID: 36536340 PMCID: PMC9764475 DOI: 10.1186/s12879-022-07638-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/20/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Febrile illnesses are among the most important reasons for medical consultation in sub-Saharan Africa and are frequently treated with antimicrobials due to the unavailability of appropriate diagnostic tools. This practice leads to antimicrobial resistance, with increasing mortality and morbidity as result. One of the few accessible diagnostic tools available in low resource settings is malaria rapid diagnostic tests (mRDTs) which contributed to reducing the over-prescription of anti-malarials, but cannot guide antibiotic prescriptions. To circumvent this problem, we explored whether combined testing with mRDT and c-reactive protein (CRP) could improve the diagnosis of febrile illnesses and subsequent prescription of antibiotics. METHODS Clinical specimens (blood, stool and urine) collected from 396 febrile children (axillary temperature of ≥ 37.5 °C) were analyzed with rapid diagnostic tests (malaria and CRP) and microbiology culture to establish the possible cause of fever. Actual antimicrobial prescriptions given to the children were compared with those that could be given based on combined CRP-malaria testing. RESULTS In total, 68.7% (272/396) of malaria cases were diagnosed by mRDT-Pf-HRP-2. CRP test was positive in 84.3% (334/396) of the children, but bacterial infections were confirmed in 12.4% (49/396) of them. A possible cause of fever could not be established in 20.5% (81/396) of cases. Based on the diagnostic practice in place, 265 of the children with a positive mRDT-Pf-HRP-2 received anti-malarial treatment. Furthermore, 89.5% (111/124) of negative mRDT results received antibiotic treatment and 37.1% (46/124) received antimalarial treatment. Of these 124 cases, 80 had positive CRP tests and 44 negative CRP tests. If the results of CRP testing are considered, 44 CRP/mRDT negative children would not get antibiotic treatment, resulting in a 35.5% reduction in antibiotic prescriptions. However, 2 cases with a bacterial infection would be denied appropriate treatment. CONCLUSION Combining mRDT-PfHRP2 with CRP testing is particularly useful in children for whom both tests are negative as it results in a reduction of antibiotics prescriptions. However, there is a risk to miss potential severe bacterial infections and a close follow-up of these cases is strongly recommended.
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Affiliation(s)
- Massa dit Achille Bonko
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso ,grid.5650.60000000404654431Department of Medical Microbiology, Experimental Parasitology Unit, Amsterdam University Medical Centers, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
| | - Ibrahima Karama
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Francois Kiemde
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Palpouguini Lompo
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Zakaria Garba
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Sibidou Yougbaré
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Petra F. Mens
- grid.5650.60000000404654431Department of Medical Microbiology, Experimental Parasitology Unit, Amsterdam University Medical Centers, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
| | - Halidou Tinto
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Marc Christian Tahita
- grid.457337.10000 0004 0564 0509Institut de Recherche en Sciences de la Santé- Direction Régionale du Centre-Ouest/Unité de Recherche Clinique de Nanoro, IRSS-DRCO /URCN), Nanoro, Burkina Faso
| | - Henk. D. F. H. Schallig
- grid.5650.60000000404654431Department of Medical Microbiology, Experimental Parasitology Unit, Amsterdam University Medical Centers, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
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Chalmers L, Czarniak P, Hughes J, Iacob R, Lee YP, Parsons K, Parsons R, Sunderland B, Sim TF. Implementation factor mapping of a pilot study of point-of-care C-reactive protein testing for respiratory tract infections in community pharmacy. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 6:100147. [PMID: 35733607 PMCID: PMC9207564 DOI: 10.1016/j.rcsop.2022.100147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Explicit consideration of implementation factors in community pharmacy service development may facilitate widespread implementation and sustainability. Objectives This study involved mapping the methodology for the pilot study of point-of-care C-reactive protein (CRP) testing to support pharmacists' management of respiratory tract infections in Western Australian pharmacies against an implementation factor framework, focussing on the resources and training program provided to participating pharmacy staff. Methods Phase 1 involved post hoc mapping of the pilot study methodology against the framework previously described by Garcia-Cardenas et al.; phase 2 was an a priori evaluation of the resources and training program, involving pre-training, post-training, and post-pilot questionnaires administered to pharmacists and pharmacy assistants/interns. A mixed model analysis compared pharmacists' responses at the three time points. Results Employment of comprehensive strategies to optimise service feasibility and sustainability was demonstrated across the five domains of ‘professional service’, ‘pharmacy staff’, ‘pharmacy’, ‘local environment’ and ‘system’; further consideration of ‘consumer’ or ‘patient’ factors is needed to address issues such as patient refusal. Study pharmacists (n = 10) and pharmacy assistants/interns (n = 5) reported high levels of satisfaction with the training (100% ‘good’/‘excellent’). Pharmacists reported significantly improved attitudes towards, confidence in, and knowledge about CRP testing and service provision from pre- to post-training (p < 0.05). Positive perceptions were maintained at the post-pilot time point. Conclusions Post hoc mapping of implementation factors highlighted potential strengths and deficiencies of the current service model. Systematic, prospective mapping, coupled with strategies to explicitly emphasise the patient perspective, may have value in optimising service implementation or modifying future service delivery models.
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Verbakel JYJ, De Burghgraeve T, Van den Bruel A, Coenen S, Anthierens S, Joly L, Laenen A, Luyten J, De Sutter A. Antibiotic prescribing rate after optimal near-patient C-reactive protein testing in acutely ill children presenting to ambulatory care (ARON project): protocol for a cluster-randomized pragmatic trial. BMJ Open 2022; 12:e058912. [PMID: 34980633 PMCID: PMC8724812 DOI: 10.1136/bmjopen-2021-058912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Children become ill quite often, mainly because of infections, most of which can be managed in the community. Many children are prescribed antibiotics which contributes to antimicrobial resistance and reinforces health-seeking behaviour. Point-of-care C reactive protein (POC CRP) testing, prescription guidance and safety-netting advice can help safely reduce antibiotic prescribing to acutely ill children in ambulatory care as well as save costs at a systems level. METHODS AND ANALYSIS The ARON (Antibiotic prescribing Rate after Optimal Near-patient testing in acutely ill children in ambulatory care) trial is a pragmatic cluster randomized controlled superiority trial with a nested process evaluation and will assess the clinical and cost effectiveness of a diagnostic algorithm, which includes a standardised clinical assessment, a POC CRP test, and safety-netting advice, in acutely ill children aged 6 months to 12 years presenting to ambulatory care. The primary outcome is antibiotic prescribing at the index consultation; secondary outcomes include clinical recovery, reconsultation, referral/admission to hospital, additional testing, mortality and patient satisfaction. We aim to recruit a total sample size of 6111 patients. All outcomes will be analysed according to the intent-to-treat approach. We will use a mixed-effect logistic regression analysis to account for the clustering at practice level. ETHICS AND DISSEMINATION The study will be conducted in compliance with the principles of the Declaration of Helsinki (current version), the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 November 2020 from the Ethics Committee Research of University Hospitals Leuven under reference S62005. We will ensure that the findings of the study will be disseminated to relevant stakeholders other than the scientific world including the public, healthcare providers and policy-makers. The process evaluation that is part of this trial may provide a basis for an implementation strategy. If our intervention proves to be clinically and cost-effective, it will be essential to educate physicians about introducing the diagnostic algorithm including POC CRP testing and safety-netting advice in their daily practice. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT04470518. Protocol V.2.0 date 2 October 2020. (Pre-results).
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Affiliation(s)
- Jan Yvan Jos Verbakel
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
| | - Ann Van den Bruel
- Department of Public Health and Primary Care, Academic Centre for General Practice, EPI-Centre, KU Leuven, Leuven, Belgium
| | - Samuel Coenen
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Wilrijk, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, Wilrijk, Belgium
- Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Louise Joly
- Research Unit Primary Care and Health, Department of General Practice, Department of Clinical Sciences, University of Liege, Liege, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Jeroen Luyten
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Department of Family Medicine & Health Policy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Implementation and Use of Point-of-Care C-Reactive Protein Testing in Nursing Homes. J Am Med Dir Assoc 2021; 23:968-975.e3. [PMID: 34626578 DOI: 10.1016/j.jamda.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents. DESIGN This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents. SETTING AND PARTICIPANTS Eleven NHs in the Netherlands. METHODS Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs. RESULTS Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice. CONCLUSIONS AND IMPLICATIONS This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.
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Niu D, Huang Q, Yang F, Tian W, Li C, Ding L, Fang HC, Zhao Y. Serum biomarkers to differentiate Gram-negative, Gram-positive and fungal infection in febrile patients. J Med Microbiol 2021; 70. [PMID: 34259621 DOI: 10.1099/jmm.0.001360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Introduction. Contamination of specimens and overuse of broad spectrum antibiotics contribute to false positives and false negatives, respectively. Therefore, useful and applicable biomarkers of bacteremia are still required.Hypothesis/Gap Statement. IL-6 can be used as a serum biomarker to discriminate among bacterial infections and fungal infections in febrile patients with a bloodstream infection.Aim. We aimed to evaluate the diagnostic efficiency of neutrophil/lymphocyte ratio (NLR), procalcitonin (PCT) and interleukin-6 (IL-6) in discriminating Gram-negative (G-) bacteria from Gram-positive (G+) bacteria and fungi in febrile patients.Methodology. A total of 567 patients with fever were evaluated. Serum levels of IL-6, PCT, NLR and CRP were compared among a G- group (n=188), a G+ group (n=168), a fungal group (n=38) and a culture negative group (n=173). Sensitivity, specificity, Yuden's index and area under the Receiver operating characteristic (ROC) curve (AUC) were obtained to analyse the diagnostic abilities of these biomarkers in discriminating bloodstream infection caused by different pathogens.Results. Serum IL-6 and PCT in the G- group increased significantly when compared with both the G+ group and fungal group (P <0.05). AUC of IL-6 (0.767, 95 % CI:0.725-0.805) is higher than AUC of PCT (0.751, 95 % CI:0.708-0.796) in discriminating the G- group from G+ group. When discriminating the G- group from fungal group, the AUC of IL-6 (0.695, 95 % CI:0.651-0.747) with a cut-off value of 464.3 pg ml-1 was also higher than the AUC of PCT (0.630, 95 % CI:0.585-0.688) with a cut-off value of 0.68 ng ml-1. Additionally, AUC of NLR (0.685, 95 % CI:0.646-0.727) in discriminating the fungal group from G+ group at the cut-off value of 9.03, was higher than AUC of IL-6, PCT and CRP.Conclusion. This study suggests that IL-6 could be used as a serum biomarker to discriminate among bacterial infections and fungal infections in febrile patients with a bloodstream infection. In addition, NLR is valuable to discriminate fungal infections from Gram-positive infections in febrile patients with a bloodstream infection.
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Affiliation(s)
- Dongguang Niu
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Hai'er road 59 Qingdao, Shandong, 266000, PR China
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, 210002, Nanjing, Jiangsu, PR China
| | - Qian Huang
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, 210002, Nanjing, Jiangsu, PR China
| | - Fan Yang
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, 210002, Nanjing, Jiangsu, PR China
| | - Weiliang Tian
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, 210002, Nanjing, Jiangsu, PR China
| | - Chen Li
- Oncology Department, Xintai people's Hospital, Tai'an, Shandong, PR China
| | - Lian'an Ding
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Hai'er road 59 Qingdao, Shandong, 266000, PR China
| | - Hong-Chun Fang
- Gastrointestinal Surgery Department, Affiliated Hospital of Qingdao University, Hai'er road 59 Qingdao, Shandong, 266000, PR China
| | - Yunzhao Zhao
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, 210002, Nanjing, Jiangsu, PR China
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10
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Verougstraete N, Verbeke F, Delanghe JR. Exogenous triglycerides interfere with a point of care CRP assay: a pre-analytical caveat. Clin Chem Lab Med 2021; 59:e141-e143. [PMID: 33035182 DOI: 10.1515/cclm-2020-1301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/28/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Nick Verougstraete
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Frederick Verbeke
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Joris R Delanghe
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
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11
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Sim TF, Chalmers L, Czarniak P, Hughes J, Iacob R, Lee YP, Parsons K, Parsons R, Sunderland B. Point-of-care C-reactive protein testing to support the management of respiratory tract infections in community pharmacy: A feasibility study. Res Social Adm Pharm 2021; 17:1719-1726. [PMID: 33500197 DOI: 10.1016/j.sapharm.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/10/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Point-of-care (POC) C-reactive protein (CRP) testing is employed in European primary care settings to differentiate viral from bacterial respiratory tract infections (RTIs) the latter, requiring referral for antibiotics. This service has yet to be trialled in Australian community pharmacy to support over-the-counter RTI management. OBJECTIVES To evaluate the feasibility, based on clinical and operational outcomes, of POC CRP testing to support Western Australian community pharmacists' management of RTIs. METHODS Patients with RTI signs and symptoms were recruited from June-August 2019 at 5 community pharmacies. Trained pharmacists made recommendations based on participants' POC CRP levels and routine clinical assessment. Participants completed questionnaires and telephone follow-ups on Days 3 (by pharmacists) and 5 (by researchers) post-testing. Service provision and uptake were assessed in 3 separate weekly tally sheets. RESULTS Clinical outcomes: CRP levels among the 131 participants recruited were: < 5 mg/L (bacterial infection unlikely; n = 60; 45.8%); 5-19 mg/L (bacterial infection possible if suggestive routine assessment; n = 52; 39.7%) and 20-100 mg/L (bacterial infection likely if suggestive routine assessment; n = 19; 14.5%). Pharmacists' management included over-the-counter medicines (131, 100%), self-care advice (125, 95.4%) and immediate general practitioner (GP) referral (15, 11.5%). Sixty-five percent (76/117) of participants had recovered by Day 5. Operational outcomes: The services was provided in 21.2% of eligible RTI presentations, representing a service uptake rate of 28.1%. Post-CRP testing, 50.9% (58/114) of participants had changed perceptions regarding their need for antibiotics, with 14.3% (16/112) subsequently intending to seek a GP prescription. Consumer satisfaction was high (100%) and most participants (93.4%, 123/131) would utilise the service again. CONCLUSIONS POC CRP testing was a feasible and well-accepted strategy to facilitate community pharmacy as a triage point for RTI. Consumer confidence in the pharmacists' advice, supported by CRP testing, potentially reduced unnecessary GP visits and antibiotic prescribing.
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Affiliation(s)
- Tin Fei Sim
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Leanne Chalmers
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Petra Czarniak
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Jeffery Hughes
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Rebecca Iacob
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Ya Ping Lee
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Kiran Parsons
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Richard Parsons
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
| | - Bruce Sunderland
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, Western Australia, 6102, Australia.
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12
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van Griensven J, Cnops L, De Weggheleire A, Declercq S, Bottieau E. Point-of-Care Biomarkers to Guide Antibiotic Prescription for Acute Febrile Illness in Sub-Saharan Africa: Promises and Caveats. Open Forum Infect Dis 2020; 7:ofaa260. [PMID: 32818139 PMCID: PMC7423291 DOI: 10.1093/ofid/ofaa260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/26/2020] [Indexed: 01/21/2023] Open
Abstract
Empiric malaria treatment in Sub-Saharan Africa has significantly decreased with the scaling-up of malaria rapid diagnostic tests; this coincided with a pronounced increase in empiric antibiotic prescriptions. In high-income countries, guidance for antibiotic prescriptions using biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT) has reduced antibiotic use while safe-guarding patient safety. Importantly, several low-cost point-of-care CRP/PCT tests are currently available. However, only a few studies on the role of CRP/PCT in differentiating bacterial vs viral infections in acute febrile illness have been conducted in Sub-Saharan Africa. Studies from Central and West Africa (most of which is malaria-endemic) are particularly scarce, and only 1 has included adults. The evidence base for point-of-care use of CRP/PCT biomarkers in acute fever in Sub-Saharan Africa should be urgently built. Before engaging in clinical trials to assess clinical impact, pilot studies should be conducted to address key knowledge gaps including recommended CRP/PCT cutoff values and the effect of malaria coinfection.
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13
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Heerink JS, Gemen E, Oudega R, Hopstaken R, Geersing GJ, Kusters R. Analytical performance and user-friendliness of five novel point-of-care D-dimer assays. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:433-440. [PMID: 32459511 DOI: 10.1080/00365513.2020.1768586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
D-dimer testing combined with a clinical assessment has become a standard pathway for ruling-out venous thromboembolism (VTE). Recently, novel Point-of-Care (POC) D-dimer assays have been introduced, enabling low-volume blood sampling for rapid exclusion of VTE in a one-step procedure. We assessed the analytical validity and user-friendliness of a set of these novel POC D-dimer assays, and compared the results with a standard laboratory assay. Plasma samples were run on our reference assay (STA-Liatest D-di PLUS®) and five POC assays: Nano-Checker 710®, AFIAS-1®; iChroma-II®; Standard F200® and Hipro AFS/1®). After evaluating imprecision, Pearson Product-Moment correlation coefficients were calculated, Passing Bablok regression was performed and Bland-Altman plots were generated. User-friendliness was evaluated using the System Usability Scale (SUS). A set of 238 plasma samples of patients clinically suspected of VTE in general practice was available for analysis. Only one POC D-dimer assay (Nano-Checker 710) demonstrated an insufficient degree of imprecision. Pearson correlation coefficients and mean biases ranged from 0.68 to 0.93 and -165 to -53 μg/L respectively, and concordance with our reference assay varied from 71.8% to 89.5% using a 500 μg/L cut-off point. While we found considerable variation in overall user-friendliness, most devices were judged easy to use. In view of our findings regarding analytical performance and user-friendliness, we consider most of the novel POC D-dimer assays can be used in settings outside of the laboratory such as general practice, combining the possibility of multi-testing with low-volume capillary blood sampling and processing times of less than 15 min.
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Affiliation(s)
- Jorn S Heerink
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Eugenie Gemen
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Ruud Oudega
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.,Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Geert-Jan Geersing
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ron Kusters
- Department of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
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14
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Boere TM, van Buul LW, Hopstaken RM, Veenhuizen RB, van Tulder MW, Cals JWL, Verheij TJM, Hertogh CMPM. Using point-of-care C-reactive protein to guide antibiotic prescribing for lower respiratory tract infections in elderly nursing home residents (UPCARE): study design of a cluster randomized controlled trial. BMC Health Serv Res 2020; 20:149. [PMID: 32103747 PMCID: PMC7045632 DOI: 10.1186/s12913-020-5006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/15/2022] Open
Abstract
Background Antibiotics are over-prescribed for lower respiratory tract infections (LRTI) in nursing home residents due to diagnostic uncertainty. Inappropriate antibiotic use is undesirable both on patient level, considering their exposure to side effects and drug interactions, and on societal level, given the development of antibiotic resistance. C-reactive protein (CRP) point-of-care testing (POCT) may be a promising diagnostic tool to reduce antibiotic prescribing for LRTI in nursing homes. The UPCARE study will evaluate whether the use of CRP POCT for suspected LRTI is (cost-) effective in reducing antibiotic prescribing in the nursing home setting. Methods/design A cluster randomized controlled trial will be conducted in eleven nursing homes in the Netherlands, with the nursing home as the unit of randomization. Residents with suspected LRTI who reside at a psychogeriatric, somatic, or geriatric rehabilitation ward are eligible for study participation. Nursing homes in the intervention group will provide care as usual with the possibility to use CRP POCT, and the control group will provide care as usual without CRP POCT for residents with (suspected) LRTI. Data will be collected from September 2018 for approximately 1.5 year, using case report forms that are integrated in the electronic patient record system. The primary study outcome is antibiotic prescribing for suspected LRTI at index consultation (yes/no). Discussion This is the first randomised trial to evaluate the effect of nursing home access to and training in the use of CRP POCT on antibiotic prescribing for LRTI, yielding high-level evidence and contributing to antibiotic stewardship in the nursing home setting. The relatively broad inclusion criteria and the pragmatic study design add to the applicability and generalizability of the study results. Trial registration Netherlands Trial Register, Trial NL5054. Registered 29 August 2018.
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Affiliation(s)
- Tjarda M Boere
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | - Laura W van Buul
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.
| | | | - Ruth B Veenhuizen
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands
| | | | - Jochen W L Cals
- Department of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Theo J M Verheij
- National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands.,Department of General Practice, Julius Centrum, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cees M P M Hertogh
- Department of General Practice & Old Age Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, the Netherlands.,National lnstitute for Public Health and the Environment (RlVM), Bilthoven, the Netherlands
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15
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Lubell Y, Chandna A, Smithuis F, White L, Wertheim HFL, Redard-Jacot M, Katz Z, Dondorp A, Day N, White N, Dittrich S. Economic considerations support C-reactive protein testing alongside malaria rapid diagnostic tests to guide antimicrobial therapy for patients with febrile illness in settings with low malaria endemicity. Malar J 2019; 18:442. [PMID: 31878978 PMCID: PMC6933672 DOI: 10.1186/s12936-019-3059-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 12/08/2019] [Indexed: 11/16/2022] Open
Abstract
Malaria is no longer a common cause of febrile illness in many regions of the tropics. In part, this success is a result of improved access to accurate diagnosis and effective anti-malarial treatment, including in many hard-to-reach rural areas. However, in these settings, management of other causes of febrile illness remains challenging. Health systems are often weak and other than malaria rapid tests no other diagnostics are available. With millions of deaths occurring annually due to treatable bacterial infections and the ever increasing spread of antimicrobial resistance, improvement in the management of febrile illness is a global public health priority. Whilst numerous promising point-of-care diagnostics are in the pipeline, substantial progress can be made in the interim with existing tools: C-reactive protein (CRP) is a highly sensitive and moderately specific biomarker of bacterial infection and has been in clinical use for these purposes for decades, with dozens of low-cost devices commercially available. This paper takes a health-economics approach to consider the possible advantages of CRP point-of-care tests alongside rapid diagnostic tests for malaria, potentially in a single multiplex device, to guide antimicrobial therapy for patients with febrile illness. Three rudimentary assessments of the costs and benefits of this approach all indicate that this is likely to be cost-effective when considering the incremental costs of the CRP tests as compared with either (i) the improved health outcomes for patients with bacterial illnesses; (ii) the costs of antimicrobial resistance averted; or (iii) the economic benefits of better management of remaining malaria cases and shorter malaria elimination campaigns in areas of low transmission. While CRP-guided antibiotic therapy alone cannot resolve all challenges associated with management of febrile illness in remote tropical settings, in the short-term a multiplexed CRP and malaria RDT could be highly cost-effective and utilize the well-established funding and distribution systems already in place for malaria RDTs. These findings should spark further interest amongst industry, academics and policy-makers in the development and deployment of such diagnostics, and discussion on their geographically appropriate use.
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Affiliation(s)
- Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Arjun Chandna
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.
| | - Frank Smithuis
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
| | - Lisa White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Heiman F L Wertheim
- Department of Medical Microbiology, Medical Center for Infectious Diseases, Radboud University, Radboudumc, Nijmegen, The Netherlands
| | - Maël Redard-Jacot
- Foundation of Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Zachary Katz
- Foundation of Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Arjen Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicholas Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Nicholas White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Sabine Dittrich
- Foundation of Innovative New Diagnostics (FIND), Geneva, Switzerland
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16
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Proft F, Muche B, Spiller L, Rios Rodriguez V, Rademacher J, Weber AK, Lüders S, Protopopov M, Redeker I, Spiller I, Sieper J, Poddubnyy D. Performance of the Ankylosing Spondylitis Disease Activity Score based on a quick quantitative C-reactive protein assay in patients with axial spondyloarthritis. Joint Bone Spine 2019; 87:69-73. [PMID: 31369867 DOI: 10.1016/j.jbspin.2019.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/17/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the performance of the Ankylosing Spondylitis Disease Activity Score based on a validated quick quantitative C-reactive protein assay (ASDAS-qCRP) as compared to ASDAS based on a routine lab CRP assay (ASDAS-CRP) and ASDAS based on erythrocyte sedimentation rate (ASDAS-ESR). METHODS Disease activity assessment was performed in 50 patients with axial spondyloarthritis (axSpA). Routine lab CRP was measured in the central lab while the quantitative quick-CRP assay and ESR measurements were performed locally. ASDAS-CRP, ASDAS-qCRP and ASDAS-ESR were subsequently calculated. RESULTS The mean (±SD) serum level of the routine lab CRP (6.2±8.3mg/l) was lower than of the quick-CRP (7.4±8.4mg/l) (P<0.05). Whereat, there was no significant difference in the mean values of ASDAS-CRP and ASDAS-qCRP in axSpA patients (2.70±0.94 and 2.74±0.96, respectively, P=0.069), while the ASDAS-ESR (2.85±1.0) was significantly higher than ASDAS-CRP (P=0.036) and numerically higher than ASDAS-qCRP (P=0.125). In 47 of the 50 cases of axSpA (94%), patients were assigned to the same disease activity category according to ASDAS-CRP and ASDAS-qCRP. CONCLUSIONS ASDAS-qCRP performed similarly well compared to ASDAS-CRP with the absolute agreement on the disease activity category according to the ASDAS of 94%. ASDAS-qCRP is, therefore, feasible for an immediate decision-making in clinical practice and trials aimed at treating to target.
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Affiliation(s)
- Fabian Proft
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Burkhard Muche
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Laura Spiller
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Valeria Rios Rodriguez
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Judith Rademacher
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Anne-Katrin Weber
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Susanne Lüders
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Mikhail Protopopov
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Imke Redeker
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Inge Spiller
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Joachim Sieper
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany; Epidemiology unit, German Rheumatism Research Centre, Berlin, Germany
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17
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A multicenter evaluation of a point of care CRP Test. Clin Biochem 2019; 71:38-45. [PMID: 31233734 DOI: 10.1016/j.clinbiochem.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Point-of-care (POC) C-reactive protein (CRP) testing in the primary healthcare setting is a cost-effective approach for reducing antibiotic prescriptions, but has yet to be widely adopted. METHODS Analytical performance of the cobas CRP Test on the cobas b 101 system was evaluated at three POC sites and one reference laboratory. Within-run (repeatability), within-laboratory (intermediate precision), and between-laboratory precision (reproducibility) were assessed. Method comparison (reference test: CRPNX reagent [cobas c 501 module]) and matrix/lot-to-lot comparison experiments were conducted using prospectively collected blood samples from 217 adults (apparently healthy or with clinically relevant conditions). Usability and reliability were assessed by questionnaire and error reporting. RESULTS Coefficients of variation (CV) for repeatability and intermediate precision ranged from 1.7%-4.0% and 1.9%-4.5%, respectively, for human serum pools containing CRP 4.7-350.7 mg/L; repeatability in clinical samples ranged from 1.6%-5.9% (3.3-360.3 mg/L). CVs for reproducibility ranged from 2.5%-4.0% (4.7-344.3 mg/L). CRP concentrations were comparable for capillary whole blood, serum, Li-heparin whole blood/plasma, K2 and K3 EDTA whole blood/plasma (Pearson's r ≥ 0.996), and among three CRP Test lots (r ≥ 0.993). Clinically relevant CRP concentrations measured with the CRP Test showed good agreement with those measured by CRPNX reagent (serum, weighted Deming regression y = 0.97× + 0.11; Pearson's r ≥ 0.996). The overall mean usability score was 4.18/5 and the error rate across 9378 tests was 1.00%. CONCLUSIONS The cobas CRP Test on the cobas b 101 system demonstrates robust analytic performance when used by healthcare professionals in the POC setting.
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18
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Verbakel JY, Lee JJ, Goyder C, Tan PS, Ananthakumar T, Turner PJ, Hayward G, Van den Bruel A. Impact of point-of-care C reactive protein in ambulatory care: a systematic review and meta-analysis. BMJ Open 2019; 9:e025036. [PMID: 30782747 PMCID: PMC6361331 DOI: 10.1136/bmjopen-2018-025036] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/02/2018] [Accepted: 12/12/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The aim of this review was to collate all available evidence on the impact of point-of-care C reactive protein (CRP) testing on patient-relevant outcomes in children and adults in ambulatory care. DESIGN This was a systematic review to identify controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services. Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane CENTRAL, DARE, Science Citation Index were searched from inception to March 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Controlled studies assessing the impact of point-of-care CRP in patients presenting to ambulatory care services, measuring a change in clinical care, including but not limited to antibiotic prescribing rate, reconsultation, clinical recovery, patient satisfaction, referral and additional tests. No language restrictions were applied. DATA EXTRACTION Data were extracted on setting, date of study, a description of the intervention and control group, patient characteristics and results. Methodological quality of selected studies and assessment of potential bias was assessed independently by two authors using the Cochrane Risk of Bias tool. RESULTS 11 randomised controlled trials and 8 non-randomised controlled studies met the inclusion criteria, reporting on 16 064 patients. All included studies had a high risk of performance and selection bias. Compared with usual care, point-of-care CRP reduces immediate antibiotic prescribing (pooled risk ratio 0.81; 95% CI 0.71 to 0.92), however, at considerable heterogeneity (I2=72%). This effect increased when guidance on antibiotic prescribing relative to the CRP level was provided (risk ratios of 0.68; 95% CI 0.63 to 0.74 in adults and 0.56; 95% CI 0.33 to 0.95 in children). We found no significant effect of point-of-care CRP testing on patient satisfaction, clinical recovery, reconsultation, further testing and hospital admission. CONCLUSIONS Performing a point-of-care CRP test in ambulatory care accompanied by clinical guidance on interpretation reduces the immediate antibiotic prescribing in both adults and children. As yet, available evidence does not suggest an effect on other patient outcomes or healthcare processes. PROSPERO REGISTRATION NUMBER CRD42016035426; Results.
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Affiliation(s)
- Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Joseph J Lee
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Clare Goyder
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Pui San Tan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Thanusha Ananthakumar
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Philip J Turner
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
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19
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Capillary-based chemiluminescence immunoassay for C-reactive protein with portable imaging device. Anal Bioanal Chem 2018; 410:7177-7183. [DOI: 10.1007/s00216-018-1321-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/02/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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20
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Matheeussen V, Van Hoof V, Loens K, Lammens C, Vanderstraeten A, Coenen S, Butler CC, Little P, Verheij TJM, Goossens H, Ieven M. Analytical performance of a platform for point-of-care CRP testing in adults consulting for lower respiratory tract infection in primary care. Eur J Clin Microbiol Infect Dis 2018; 37:1319-1323. [DOI: 10.1007/s10096-018-3253-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/05/2018] [Indexed: 11/24/2022]
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21
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Aertgeerts B, Bullens DMA, Shinkins B, Van den Bruel A, Buntinx F. Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study. Arch Dis Child 2018; 103:420-426. [PMID: 29269559 DOI: 10.1136/archdischild-2016-312384] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Acute infection is the most common presentation of children to hospital. A minority of these infections are serious, but early recognition and adequate management are essential. We aimed to develop improved tools to assess children attending ambulatory hospital care, integrating clinical features with point-of-care C reactive protein (CRP). DESIGN Prospective observational diagnostic study. SETTING AND PATIENTS 5517 acutely ill children (1 month-16 years) presenting to 106 paediatricians at six outpatient clinics and six emergency departments in Belgium. INDEX TEST Point-of-care CRP alongside vital signs and objective symptoms measurements. MAIN OUTCOME Hospital admission for >24 hours with a serious infection <5 days after presentation. RESULTS An algorithm was developed consisting of clinical features and CRP. This achieved 97.1% (95% CI 94.3% to 98.7%) sensitivity and 99.6% (95% CI 99.2% to 99.8%) negative predictive value, excluding serious infections in 36.4% of children. It stratifies patients into three groups based on CRP level: high-risk group with CRP >75 mg/L (26.8% risk of infection), intermediate-risk group with CRP 20-75 mg/L and at least one of seven clinical features (8.1%), and lower risk group with CRP <20 mg/L with at least one of the 11 features (3.8%). Children in intermediate-risk or low-risk groups with normal clinical assessment have 0.6% and 0.4% risk of serious infections, respectively. CONCLUSIONS Conducting a CRP test may first enable children to be stratified into three risk groups, guiding assessment of clinical features that could be performed by junior doctors or nurses. In one-third of acutely ill children, the algorithm could exclude serious infection. Prospective validation of the algorithm is needed. CLINICAL TRIAL REGISTRATION NCT02024282 (post-results).
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Affiliation(s)
- Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marieke B Lemiengre
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | | | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Dominique M A Bullens
- Clinical Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium.,Paediatric Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Research Institute CAPHRI, Maastricht University, Maastricht, The Netherlands
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22
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Trippella G, Galli L, de Martino M, Chiappini E. Inflammatory biomarkers to guide diagnostic and therapeutic decisions in children presenting with fever without apparent source. J Chemother 2018; 30:255-265. [DOI: 10.1080/1120009x.2018.1451430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Giulia Trippella
- Department of Health Science, Post-graduate School of Pediatrics, Anna Meyer Children’s University Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Division of Pediatric Infectious Disease, Department of Health Science, Anna Meyer Children’s University Hospital, University of Florence, Florence, Italy
| | | | - Elena Chiappini
- Division of Pediatric Infectious Disease, Department of Health Science, Anna Meyer Children’s University Hospital, University of Florence, Florence, Italy
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23
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Howick J, Bossuyt PM, Cals JWL. Point of care testing in family practice: common myths debunked. Fam Pract 2017; 34:373-375. [PMID: 27543793 DOI: 10.1093/fampra/cmw082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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24
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Pecoraro V, Banfi G, Germagnoli L, Trenti T. A systematic evaluation of immunoassay point-of-care testing to define impact on patients' outcomes. Ann Clin Biochem 2017; 54:420-431. [PMID: 28135840 DOI: 10.1177/0004563217694377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Point-of-care testing has been developed to provide rapid test results. Most published studies focus on analytical performance, neglecting its impact on patient outcomes. Objective To review the analytical performance and accuracy of point-of-care testing specifically planned for immunoassay and to evaluate the impact of faster results on patient management. Methods A search of electronic databases for studies reporting immunoassay results obtained in both point-of-care testing and central laboratory scenarios was performed. Data were extracted concerning the study details, and the methodological quality was assessed. The analytical characteristics and diagnostic accuracy of six points-of-care testing: troponin, procalcitonin, parathyroid hormone, brain natriuretic peptide, C-reactive protein and neutrophil gelatinase-associated lipocalin were evaluated. Results A total of 116 scientific papers were analysed. Studies measuring procalcitonin, parathyroid hormone and neutrophil gelatinase-associated lipocalin reported a limited impact on diagnostic decisions. Seven studies measuring C-reactive protein claimed a significant reduction of antibiotic prescription. Several authors evaluated brain natriuretic peptide or troponin reporting faster decision-making without any improvement in clinical outcome. Forty-four per cent of studies reported analytical data, showing satisfactory correlations between results obtained through point-of-care testing and central laboratory setting. Half of studies defined the diagnostic accuracy of point-of-care testing as acceptable for troponin (median sensitivity and specificity: 74% and 94%, respectively), brain natriuretic peptide (median sensitivity and specificity: 82% and 88%, respectively) and C-reactive protein (median sensitivity and specificity 85%). Conclusions Point-of-care testing immunoassay results seem to be reliable and accurate for troponin, brain natriuretic peptide and C-reactive protein. The satisfactory analytical performance, together with an excellent practicability, suggests that it could be a consistent tool in clinical practice, but data are lacking regarding the patient outcomes.
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Affiliation(s)
- Valentina Pecoraro
- 1 Department of Laboratory Medicine, Clinical Pathology-Toxicology, Ospedale Civile Sant'Agostino Estense, Modena, Italy.,2 Laboratory of Regulatory Policies, IRCCS - "Mario Negri", Institute of Pharmacological Research, Milan, Italy
| | - Giuseppe Banfi
- 3 Vita-Salute San Raffaele University, Milan, Italy.,4 I.R.C.C.S. Orthopedic Institute Galeazzi, Milan, Italy
| | | | - Tommaso Trenti
- 1 Department of Laboratory Medicine, Clinical Pathology-Toxicology, Ospedale Civile Sant'Agostino Estense, Modena, Italy
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25
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Bukve T, Stavelin A, Sandberg S. Effect of Participating in a Quality Improvement System over Time for Point-of-Care C-Reactive Protein, Glucose, and Hemoglobin Testing. Clin Chem 2016; 62:1474-1481. [DOI: 10.1373/clinchem.2016.259093] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/20/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Users of point-of-care testing (POCT) in Norway participate in a quality improvement system that includes education and guidance in safe laboratory management along with participation in external quality assurance schemes (EQAS).
The aim of this study was to identify the effect on the analytical performance of POCT C-reactive protein (CRP), glucose, and hemoglobin (Hb) with the use of a quality improvement system over time and to identify which factors are associated with good performance.
METHODS
Participants' results from 19 EQAS for CRP, glucose, and Hb from 2006 to 2015 along with information on the instruments used and different practice characteristics were analyzed. Logistic regression analysis was used to evaluate the factors associated with good laboratory performance. An instrument evaluation and comparison for CRP determination was performed by using commutable EQA material.
RESULTS
The mean number of participants in each EQAS was 2134, 2357, and 2271 for CRP, glucose, and Hb, respectively. The percentage of good participant performances increased gradually whereas that of poor performances decreased with participation in a quality improvement system over 9 years for all 3 analytes. Independent factors associated with good performance were type of instrument, the number of times performing EQA, performing internal QC weekly, performing 10 or more tests weekly, and having laboratory-qualified personnel perform the tests. Considering CRP instrument performance, Afinion and QuikRead exhibited the lowest systematic deviation.
CONCLUSIONS
The analytical quality of CRP, glucose, and Hb testing is improved by systematic participation in a quality improvement system over time.
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Affiliation(s)
- Tone Bukve
- The Norwegian Quality Improvement of Primary Care Laboratories (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Anne Stavelin
- The Norwegian Quality Improvement of Primary Care Laboratories (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Sverre Sandberg
- The Norwegian Quality Improvement of Primary Care Laboratories (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Global Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
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26
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Verbakel JY, Lemiengre MB, De Burghgraeve T, De Sutter A, Aertgeerts B, Shinkins B, Perera R, Mant D, Van den Bruel A, Buntinx F. Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial. BMC Med 2016; 14:131. [PMID: 27716201 PMCID: PMC5052874 DOI: 10.1186/s12916-016-0679-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment. METHODS Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature ≥ 40 °C, diarrhoea and age 12-30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L. RESULTS Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 % (95 % CI, 77.8-82.0 %). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 % vs. 0.14 %, P = 0.88). Only one child with a CRP < 5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 %, 95 % CI, 19.6-45.6 %) had a CRP < 5 mg/L. CONCLUSIONS CRP testing should be restricted to children at higher risk after clinical assessment. A CRP < 5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02024282 (registered on 14th September 2012).
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Affiliation(s)
- Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK. .,Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium.
| | - Marieke B Lemiengre
- Department of Family Medicine and Primary Health Care, Ghent University, De Pintelaan 185, Gent, 9000, Belgium
| | - Tine De Burghgraeve
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium
| | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, De Pintelaan 185, Gent, 9000, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, 101 Clarendon Road, Leeds, LS29LJ, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford, OX2 6GG, UK
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33J, 3000, Leuven, Belgium.,Research Institute Caphri, Maastricht University, Universiteitssingel 40, Maastricht, 6229 ER, The Netherlands
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27
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Minnaard MC, de Groot JAH, Hopstaken RM, Schierenberg A, de Wit NJ, Reitsma JB, Broekhuizen BDL, van Vugt SF, Neven AK, Graffelman AW, Melbye H, Rainer TH, Steurer J, Holm A, Gonzales R, Dinant GJ, van de Pol AC, Verheij TJM. The added value of C-reactive protein measurement in diagnosing pneumonia in primary care: a meta-analysis of individual patient data. CMAJ 2016; 189:E56-E63. [PMID: 27647618 DOI: 10.1503/cmaj.151163] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 05/12/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND C-reactive protein (CRP) is increasingly being included in the diagnostic work-up for community-acquired pneumonia in primary care. Its added diagnostic value beyond signs and symptoms, however, remains unclear. We conducted a meta-analysis of individual patient data to quantify the added value of CRP measurement. METHODS We included studies of the diagnostic accuracy of CRP in adult outpatients with suspected lower respiratory tract infection. We contacted authors of eligible studies for inclusion of data and for additional data as needed. The value of adding CRP measurement to a basic signs-and-symptoms prediction model was assessed. Outcome measures were improvement in discrimination between patients with and without pneumonia in primary care and improvement in risk classification, both within the individual studies and across studies. RESULTS Authors of 8 eligible studies (n = 5308) provided their data sets. In all of the data sets, discrimination between patients with and without pneumonia improved after CRP measurement was added to the prediction model (extended model), with a mean improvement in the area under the curve of 0.075 (range 0.02-0.18). In a hypothetical cohort of 1000 patients, the proportion of patients without pneumonia correctly classified at low risk increased from 28% to 36% in the extended model, and the proportion with pneumonia correctly classified at high risk increased from 63% to 70%. The number of patients with pneumonia classified at low risk did not change (n = 4). Overall, the proportion of patients assigned to the intermediate-risk category decreased from 56% to 51%. INTERPRETATION Adding CRP measurement to the diagnostic work-up for suspected pneumonia in primary care improved the discrimination and risk classification of patients. However, it still left a substantial group of patients classified at intermediate risk, in which clinical decision-making remains challenging.
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Affiliation(s)
- Margaretha C Minnaard
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Joris A H de Groot
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rogier M Hopstaken
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Alwin Schierenberg
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Niek J de Wit
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Johannes B Reitsma
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Berna D L Broekhuizen
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Saskia F van Vugt
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Arie Knuistingh Neven
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Aleida W Graffelman
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hasse Melbye
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Timothy H Rainer
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Johann Steurer
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Anette Holm
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ralph Gonzales
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Geert-Jan Dinant
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Alma C van de Pol
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Theo J M Verheij
- University Medical Center Utrecht (Minnaard, de Groot, Schierenberg, de Wit, Reitsma, Broekhuizen, van Vugt, van de Pol, Verheij), Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands; Saltro Diagnostic Center for Primary Care (Hopstaken), Utrecht, the Netherlands; Department of Public Health and Primary Care (Knuistingh Neven, Graffelman), Leiden University Medical Center, Leiden, the Netherlands; Department of Community Medicine (Melbye), UiT the Arctic University of Norway, Tromsø, Norway; Chinese University of Hong Kong (Rainer), Hong Kong, China; Horten Centre for Patient Oriented Research and Knowledge Transfer (Steurer), University Zurich, Zurich, Switzerland; Department of Infectious Diseases (Holm), Odense University Hospital, Odense, Denmark; Division of General Internal Medicine (Gonzales), University of California, San Francisco, Calif.; Department of Family Medicine (Dinant), CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, the Netherlands
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Minnaard MC, van der Zand J, van de Pol AC, de Wit NJ, Schierenberg A, Hopstaken RM, van Delft S, Verheij TJM, Broekhuizen BDL. Analysis of recruitment in a pragmatic observational study on C-reactive protein point-of-care testing in primary care. Eur J Gen Pract 2016; 22:219-224. [PMID: 27485531 DOI: 10.1080/13814788.2016.1208167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Failure to recruit all eligible study patients can lead to biased results. Little is known on selective patient recruitment in studies on implementation of diagnostic devices. OBJECTIVES The aim of this observational study was to measure recruitment of patients in an implementation study in primary care on use of point-of-care (POC) C-reactive protein (CRP) and to evaluate recruitment bias and its impact on the study endpoint. METHODS In a cross-sectional observational study on POC CRP implementation and related antibiotics prescribing, we compared included patients with all eligible patients to assess the representativeness of the included subjects. Eligible patients were adults presenting with acute cough in primary care between March and September 2012. The frequency of POC CRP testing and the proportion of prescribed antibiotics were compared between recruited and non-recruited patients. As measure of bias, odds ratios (ORs) with accompanying 95% confidence intervals (CIs) for the association between CRP level (<20 mg/l or not) and antibiotic prescribing were computed. RESULTS Of all 1473 eligible patients 348 (24%) were recruited. In recruited patients, POC CRP tests were conducted and antibiotics prescribed more frequently as compared to non-recruited patients (81% versus 6% and 44% versus 29%, respectively). The ORs were 18.2 (95%CI: 9.6-34.3), 30.5 (95%CI: 13.2-70.3) and 3.8 (95%CI: 0.9-14.8) respectively in all eligible patients, the recruited and the non-recruited patients. CONCLUSION Selective recruitment resulted in an overestimation of POC CRP test use and antibiotic prescribing.
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Affiliation(s)
- Margaretha C Minnaard
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
| | - Janna van der Zand
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
| | - Alma C van de Pol
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
| | - Niek J de Wit
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
| | - Alwin Schierenberg
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
| | - Rogier M Hopstaken
- b Saltro, Diagnostic Center for Primary Care , Utrecht , the Netherlands
| | - Sanne van Delft
- b Saltro, Diagnostic Center for Primary Care , Utrecht , the Netherlands
| | - Theo J M Verheij
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
| | - Berna D L Broekhuizen
- a University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
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29
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Minnaard MC, van de Pol AC, Hopstaken RM, van Delft S, Broekhuizen BDL, Verheij TJM, de Wit NJ. C-reactive protein point-of-care testing and associated antibiotic prescribing. Fam Pract 2016; 33:408-13. [PMID: 27230745 DOI: 10.1093/fampra/cmw039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In clinical trials, the potential of point-of-care (POC) C-reactive protein (CRP) tests was demonstrated in decreasing antibiotic prescribing in adults with acute cough in general practice, but effects of implementation are unknown. OBJECTIVE To determine the overall effect of POC CRP testing on antibiotic prescribing rate in general practice. METHODS In an observational study, GPs were instructed to use POC CRP in adults with acute cough following current guidelines. After routine history taking and physical examination, they reported whether they intended to prescribe antibiotics ('pre-test decision'). They reported their revised decision after receiving the POC CRP test result ('post-test decision'). Primary outcome was the percentage of patients in whom the GP changed his or her decision to prescribe antibiotics. Secondary outcome was the difference between 'pre-test' and 'post-test' antibiotic prescribing % at group level. RESULTS A total of 40 GPs enrolled 939 patients, 78% of whom were tested for CRP. GPs changed their decision after POC CRP testing in 200 patients (27%). Antibiotic prescribing before and after CRP testing did not differ ('pre-test' 31%, 'post-test' 28%; 95% confidence interval of difference -7 to 1). In 41% of the tested patients, the indication for testing was in accordance with the guidelines. CONCLUSION POC CRP influenced GPs to change their decision about antibiotic prescribing in patients with acute cough. POC CRP testing does not reduce overall antibiotic prescribing by GPs who already have a low antibiotic prescribing rate.
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Affiliation(s)
- Margaretha C Minnaard
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | - Alma C van de Pol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | | | - Sanne van Delft
- Saltro Diagnostic Center for Primary Care, Utrecht, The Netherlands
| | - Berna D L Broekhuizen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
| | - Niek J de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands and
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30
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Accuracy of commercially available c-reactive protein rapid tests in the context of undifferentiated fevers in rural Laos. BMC Infect Dis 2016; 16:61. [PMID: 26846919 PMCID: PMC4743113 DOI: 10.1186/s12879-016-1360-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND C-Reactive Protein (CRP) has been shown to be an accurate biomarker for discriminating bacterial from viral infections in febrile patients in Southeast Asia. Here we investigate the accuracy of existing rapid qualitative and semi-quantitative tests as compared with a quantitative reference test to assess their potential for use in remote tropical settings. METHODS Blood samples were obtained from consecutive patients recruited to a prospective fever study at three sites in rural Laos. At each site, one of three rapid qualitative or semi-quantitative tests was performed, as well as a corresponding quantitative NycoCard Reader II as a reference test. We estimate the sensitivity and specificity of the three tests against a threshold of 10 mg/L and kappa values for the agreement of the two semi-quantitative tests with the results of the reference test. RESULTS All three tests showed high sensitivity, specificity and kappa values as compared with the NycoCard Reader II. With a threshold of 10 mg/L the sensitivity of the tests ranged from 87-98 % and the specificity from 91-98 %. The weighted kappa values for the semi-quantitative tests were 0.7 and 0.8. CONCLUSION The use of CRP rapid tests could offer an inexpensive and effective approach to improve the targeting of antibiotics in remote settings where health facilities are basic and laboratories are absent. This study demonstrates that accurate CRP rapid tests are commercially available; evaluations of their clinical impact and cost-effectiveness at point of care is warranted.
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Lubell Y, Blacksell SD, Dunachie S, Tanganuchitcharnchai A, Althaus T, Watthanaworawit W, Paris DH, Mayxay M, Peto TJ, Dondorp AM, White NJ, Day NPJ, Nosten F, Newton PN, Turner P. Performance of C-reactive protein and procalcitonin to distinguish viral from bacterial and malarial causes of fever in Southeast Asia. BMC Infect Dis 2015; 15:511. [PMID: 26558692 PMCID: PMC4642613 DOI: 10.1186/s12879-015-1272-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/05/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Poor targeting of antimicrobial drugs contributes to the millions of deaths each year from malaria, pneumonia, and other tropical infectious diseases. While malaria rapid diagnostic tests have improved use of antimalarial drugs, there are no similar tests to guide the use of antibiotics in undifferentiated fevers. In this study we estimate the diagnostic accuracy of two well established biomarkers of bacterial infection, procalcitonin and C-reactive protein (CRP) in discriminating between common viral and bacterial infections in malaria endemic settings of Southeast Asia. METHODS Serum procalcitonin and CRP levels were measured in stored serum samples from febrile patients enrolled in three prospective studies conducted in Cambodia, Laos and, Thailand. Of the 1372 patients with a microbiologically confirmed diagnosis, 1105 had a single viral, bacterial or malarial infection. Procalcitonin and CRP levels were compared amongst these aetiological groups and their sensitivity and specificity in distinguishing bacterial infections and bacteraemias from viral infections were estimated using standard thresholds. RESULTS Serum concentrations of both biomarkers were significantly higher in bacterial infections and malaria than in viral infections. The AUROC for CRP in discriminating between bacterial and viral infections was 0.83 (0.81-0.86) compared with 0.74 (0.71-0.77) for procalcitonin (p < 0.0001). This relative advantage was evident in all sites and when stratifying patients by age and admission status. For CRP at a threshold of 10 mg/L, the sensitivity of detecting bacterial infections was 95% with a specificity of 49%. At a threshold of 20 mg/L sensitivity was 86% with a specificity of 67%. For procalcitonin at a low threshold of 0.1 ng/mL the sensitivity was 90% with a specificity of 39%. At a higher threshold of 0.5 ng/ul sensitivity was 60% with a specificity of 76%. CONCLUSION In samples from febrile patients with mono-infections from rural settings in Southeast Asia, CRP was a highly sensitive and moderately specific biomarker for discriminating between viral and bacterial infections. Use of a CRP rapid test in peripheral health settings could potentially be a simple and affordable measure to better identify patients in need of antibacterial treatment and part of a global strategy to combat the emergence of antibiotic resistance.
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Affiliation(s)
- Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Stuart D Blacksell
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Susanna Dunachie
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Ampai Tanganuchitcharnchai
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Thomas Althaus
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Wanitda Watthanaworawit
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - Daniel H Paris
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Mayfong Mayxay
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Laos. .,Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Laos.
| | - Thomas J Peto
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - François Nosten
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand.
| | - Paul N Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMWRU), Mahosot Hospital, Vientiane, Laos.
| | - Paul Turner
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. .,Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
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Minnaard MC, van de Pol AC, de Groot JAH, De Wit NJ, Hopstaken RM, van Delft S, Goossens H, Ieven M, Lammens C, Little P, Butler CC, Broekhuizen BDL, Verheij TJM. The added diagnostic value of five different C-reactive protein point-of-care test devices in detecting pneumonia in primary care: A nested case-control study. Scandinavian Journal of Clinical and Laboratory Investigation 2015; 75:291-5. [PMID: 25723728 DOI: 10.3109/00365513.2015.1006136] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The results obtained from various point-of-care (POC) test devices for estimating C-reactive protein (CRP) levels in a laboratory setting differ when compared to a laboratory reference test. We aimed to determine whether such differences meaningfully affect the accuracy and added diagnostic value in predicting radiographic pneumonia in adults presenting with acute cough in primary care. METHODS A nested case control study of adult patients presenting with acute cough in 12 different European countries (the Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe [GRACE] Network). Venous blood samples from 100 patients with and 100 patients without pneumonia were tested with five different POC CRP tests and a laboratory analyzer. Single test accuracy values and the added value of CRP to symptoms and signs were calculated. RESULTS Single test accuracy values showed similar results for all five POC CRP tests and the laboratory analyzer. The area under the curve of the different POC CRP tests and the laboratory analyzer (range 0.79-0.80) were all comparable and higher than the clinical model without CRP (0.70). Multivariable odds ratios were the same (1.2) for all CRP tests. CONCLUSIONS Five POC CRP test devices and the laboratory analyzer performed with similar accuracy in detecting pneumonia both as single test, and when used in addition to clinical findings. Variability in results obtained from standard CRP laboratory and POC test devices do not translate into clinically relevant differences when used for prediction of pneumonia in patients with acute cough in primary care.
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Affiliation(s)
- Margaretha C Minnaard
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care , Utrecht , the Netherlands
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Validation and evaluation of eight commercially available point of care CRP methods. Clin Chim Acta 2015; 439:195-201. [DOI: 10.1016/j.cca.2014.10.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 10/01/2014] [Accepted: 10/20/2014] [Indexed: 01/22/2023]
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