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Question clinique
Does knowledge of point-of-care C-reactive protein help physicians avoid antibiotics without sacrificing benefit in patients with an exacerbation of chronic obstructive pulmonary disease?
L’Essentiel
C-reactive protein (CRP) guidance regarding the likelihood that antibiotics will be helpful for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) safely reduced antibiotic use (number needed to treat [NNT] = 5). Physicians were advised that antibiotics are unlikely to be helpful if CRP is less than 20 mg/L, that antibiotics may be helpful if CRP is 20 to 40 mg/L, especially in the presence of purulent sputum, and that antibiotics are likely to be helpful if CRP is greater than 40 mg/L. 1b-
Référence
Plan de l'etude: Randomized controlled trial (nonblinded)
Financement: Government
Cadre: Outpatient (primary care)
Sommaire
CRP is an inflammatory biomarker elevated in patients with pneumonia and bacterial rhinosinusitis, and is recommended by UK guidelines to help physicians avoid antibiotics in patients with acute lower respiratory tract infection. These authors wondered if the use of CRP would also be effective in patients with an acute exacerbation of COPD. The researchers recruited 653 patients, 40 years and older, with documented COPD who were experiencing an exacerbation. The patients were randomized to usual care or care guided by the results of a point-of-care CRP test. The guidance provided was that antibiotics are unlikely to be helpful if CRP is less than 20 mg/L, that they may be helpful if CRP is 20 to 40 mg/L (especially if the patient also has purulent sputum), and that they are likely to be beneficial if CRP is greater than 40 mg/L. They were also told that the decision should be guided by all patient factors, not just CRP. All patients met at least one of the Anthonisen criteria (increased dyspnea, increased sputum volume, and increased sputum purulence). The mean age of patients was 68 years, 52% were men, and most had GOLD stage 2 or 3 severity of their COPD. Patients were telephoned at 1 and 2 weeks, and were seen in person at 4 weeks; data on antibiotic use were available for 83%. The primary outcome was antibiotic use, which occurred significantly less often with CRP-guided care (57% vs 77%; P < .05; number needed to treat = 5). In addition, at 2 weeks patients in the CRP-guided group had greater improvement in their COPD severity score. Overall, the distribution of CRP was as follows: 76% less than 20 mg/L, 12% 20 to 40 mg/L, and 12% greater than 40 mg/L. There were also no differences among groups in other prescriptions, follow-up visits or hospitalizations in the next 6 months, or the likelihood of pneumonia. The effect of CRP guidance was greater in patients who had more of the Anthonisen criteria, and was only statistically significant for those with at least 2 of the criteria.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Commentaires
This would be more helpful…
This would be more helpful if I could get quick turnaround on c-RP testing. From the office I may get the results the next day. Chances are if I've been considering antibiotics I've already started them by then. Might be a helpful guide to stop them again I guess. In our urgent care clinic that test gets sent out to the hospital and takes several hours to come back-again not ideal.
Limites de l'étude
Je tenais simplement à spécifier que les patients hospitalisés ont été exclus et que la différence de prescription d'antibiotique n'est significative que pour > 1 critère d'Anthonisen, ce qui est dommage car c'est à ce moment qu'un test paraclinique est le plus utile.