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Oxford – Determination of C-reactive protein (CRP), which increases particularly in severe infections, may reduce the use of antibiotics in outpatient treatment of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), without the situation of To aggravate patients. This went into a randomized clinical trial New England Journal of Medicine (2019; 381: 111-120).
Every year, 25,000 people die from COPD in Germany. Globally, COPD is the third leading cause of death. It is therefore understandable that, in acute exacerbations, physicians resort to maximum treatment, including the use of antibiotics. Infections are a common cause of exacerbation. However, it is also clear that infections are not the only trigger and that antibiotics can only be effective if the infection is caused by a bacterium and not by a virus.
Until now, the doctor did not have a reliable criterion allowing him to detect the possible presence of a bacterial infection. The three criteria anthonisen (increased dyspnea, increased sputum and sputum purulence) are considered uncertain and are therefore often ignored.
The PACE study has sought in recent years to determine whether a rapid CRP test could support physician decision-making and reduce prescription of antibiotics. The study included 86 GP surgeries from England and Wales. Doctors have been given a rapid CRP test device, which they should only use in half of the patients. In total, 653 patients were included in the study. All fulfilled at least one Anthonisen criterion.
The limit of CRP was 20 mg / l
The recommendation to the doctors was that if the CRP level was below 20 mg / l, the use of antibiotics was probably not helpful and should be avoided. At a CRP level of 20 to 40 mg / L, antibiotics may be helpful and a benefit is likely for a CRP greater than 40 mg / L. The CRP value was a recommendation, the decision on the use of Antibiotics respected at the end of the doctor.
The main evaluation criteria of the study were once the frequency of antibiotic prescriptions obtained in patients four weeks after the start of the study. The second primary endpoint was the Clinical COPD Questionnaire (CCQ), in which patients scored 10 questions on the symptoms and effects of the disease on daily life at 0-6 points. The CCQ is a valid tool for assessing COPD, which is also used in Germany.
Avoiding antibiotics does not harm patients
According to Christopher Butler of the Department of Health Sciences of Primary Health Care in Nuffield, Oxford, and his colleagues, 57.0% of patients in the CRP-controlled group received a prescription for antibiotics. In the control group, it was 77.4%. The adjusted odds ratio was 0.31 and was significant with a 95% confidence interval of 0.20 to 0.47. Overall, one in five patients (20 percentage points) was more likely to refrain from prescribing antibiotics, which is a clinically significant difference.
The patient's situation has not deteriorated due to the lack of antibiotics. The difference in CCQ was only 0.19 points in favor of the CRP-led group (90% confidence interval between 0.05 and 0.33).
Patients in the CRP-controlled group were less likely to receive an antibiotic prescription at the time of the first visit (47.7% versus 69.7%, adjusted odds ratio of 0.31, 0.21 to 0). , 45). In addition, the number of prescriptions during the first four weeks of follow-up (59.1% vs. 79.7%, adjusted odds ratio, 0.30, 0.20 to 0.46) was lower.
In the CRP-controlled group, physicians had prescribed antibiotics to 79 of 241 patients (32.8%) with a CRP of less than 20 mg / L. In the CRP range of 20 to 40 mg / l, 32 38 (84.2%) received a prescription and at a CRP level of 40 mg / l, 36 out of 94 patients (94.7%). © heat / Good medical