Novel multi-virus rapid respiratory microbiological point-of-care testing in primary care: a mixed-methods feasibility evaluation

Rapid microbiological respiratory point-of-care testing: a qualitative study with primary care clinicians

BACKGROUND

Rapid microbiological point-of-care tests (RM POCTs) present an opportunity to reduce antibiotic exposure and antimicrobial resistance (AMR). So far, there is limited understanding of how RM POCTs may support clinicians in primary care in the UK and how RM POCTs might be integrated into practice.

AIM

To investigate clinicians' views on how RM POCTs can influence clinical decisions and routine practice, and perspectives on how RM POCTs can impact the clinician-patient relationship.

DESIGN AND SETTING

A qualitative study was undertaken. The study was embedded in a multi-centre, individually randomised controlled efficacy trial, which evaluated the use of a multiplex RM POCT for suspected respiratory tract infections (RTIs) in primary care.

METHOD

Individual interviews were conducted with 18 clinicians (GPs, n = 9; advanced nurse practitioners, n = 4; paramedics, n = 2; trainee advanced nurse practitioner, n = 1; clinical pharmacist, n = 1; and emergency care practitioner, n = 1). Interviews were audio-recorded, transcribed verbatim, and analysed thematically informed by a realist approach.

RESULTS

RM POCTs can guide prescribing decisions when clinicians experience diagnostic uncertainty and support communication with patients to reinforce prescribing decisions. Consequently, the perceived value of, and use of, RM POCTs varied according to clinicians' confidence in making prescribing decisions and managing patient expectations and their clinical roles. The costly and time-consuming nature of RM POCTs meant that integration of the tests into routine practice was considered unlikely at present.

CONCLUSION

The findings from this study highlight the potential benefits and challenges of integrating RM POCTs into routine practice. Clinicians in this study had generally favourable views towards RM POCTs. However, further RM POCT training, complementary strategies, such as communication skills training and patient education, and clear guidance on implementation should be explored to optimise RM POCT feasibility and outcomes across different primary care settings.

Point-of-care tests to manage acute respiratory tract infections in primary care: a systematic review and qualitative synthesis of healthcare professional and patient views

OBJECTIVES

To review the evidence on healthcare professionals' (HCPs) and patients' views of the use of point-of-care tests (POCTs) in the management of acute respiratory tract infections (RTIs) in primary care settings.

METHODS

We conducted a systematic review of studies up to 28 April 2023. We included studies that included qualitative methods and results; focused on HCPs' and/or patients' views/experiences of POCTs for acute RTIs; and were conducted in primary care settings. We conducted a thematic synthesis to identify how their views on POCTs and interventions can support test use (PROSPERO registration: CRD42019150347).

RESULTS

We included 33 studies, developing 9 categories each for HCP and patient data. We identified 38 factors affecting POCT use: 28 from HCPs and 10 from patients. Factors exist outside and within consultations, and post-consultations, illustrating that some cannot be addressed by HCPs alone. Fourteen interventions were identified that could address factors and support POCT use, with 7 interventions appearing to address the most factors. Some interventions were beyond the scope of HCPs and patients and needed to be addressed at system and organizational levels. Both groups had mixed views on the use of POCTs and highlighted implementation challenges.

DISCUSSION

This review highlights numerous factors affecting POCT use in primary care. Policy-makers planning to implement POCTs are likely to achieve more by providing multi-faceted interventions that target factors outside, within, and post-consultation. Some interventions may need to be already established before POCT introduction. Whilst evidence beyond general practice is limited, similar factors suggest that similar context-tailored interventions would be appropriate.

The adoption of point of care testing technologies for respiratory tract infections in primary care in Australia: Challenges and facilitators

Despite technological advances and readily available point of care test (POCT) devices with rapid turn-around results for respiratory tract infection (RTI) management, their adoption in primary care remains low. This paper summarises the challenges and facilitators of POCT implementation for RTIs in primary care settings in high-income countries. The review of 28 studies identified by systematic searches of electronic databases improves our understanding of the current state and will help guide the design and implementation of strategies to improve widespread POCT adoption. To effectively implement respiratory POCT in primary care, it is crucial to address several key challenges. These include ensuring the availability of resources to alleviate time pressures and costs, enhancing training, increasing quality control, improving device feasibility, and managing patient expectations. In doing so, diagnostic POCTs can contribute to an accurate, rapid, and evidence-based diagnosis of RTIs to reduce antimicrobial use and improve antimicrobial stewardship and patient outcomes.

Rapid respiratory microbiological point-of-care-testing and antibiotic prescribing in primary care: Protocol for the RAPID-TEST randomised controlled trial

BACKGROUND

Antibiotics are prescribed for over 50% of respiratory tract infections in primary care, despite good evidence of there being no benefit to the patient, and evidence of over prescribing driving microbial resistance. The high treatment rates are attributed to uncertainty regarding microbiological cause and clinical prognosis. Point-of-care-tests have been proposed as potential antibiotic stewardship tools, with some providing microbiological results in 15 minutes. However, there is little research on their impact on antibiotic use and clinical outcomes in primary care.

METHODS

This is a multi-centre, individually randomised controlled trial with mixed-methods investigation of microbial, behavioural and antibiotic mechanisms on outcomes in patients aged 12 months and over presenting to primary care in the UK with a suspected respiratory tract infection, where the clinician and/or patient thinks antibiotic treatment may be, or is, necessary. Once consented, all participants are asked to provide a combined nose and throat swab sample and randomised to have a rapid microbiological point-of-care-test or no point-of-care-test. For intervention patients, clinicians review the result of the test, before contacting the patient to finalise treatment. Treatment decisions are made as per usual care in control group patients. The primary outcome is whether an antibiotic is prescribed at this point. All swab samples are sent to the central laboratory for further testing. Patients are asked to complete a diary to record the severity and duration of symptoms until resolution or day 28, and questionnaires at 2 months about their beliefs and intention to consult for similar future illnesses. Primary care medical records are also reviewed at 6-months to collect further infection consultations, antibiotic prescribing and hospital admissions. The trial aims to recruit 514 patients to achieve 90% power with 5% significance to detect a 15% absolute reduction in antibiotic prescribing. Qualitative interviews are being conducted with approximately 20 clinicians and 30 participants to understand any changes in beliefs and behaviour resulting from the point-of-care-test and generate attributes for clinician and patient discrete choice experiments.

DISCUSSION

This trial will provide evidence of efficacy, acceptability and mechanisms of action of a rapid microbiological point-of-care test on antibiotic prescribing and patient symptoms in primary care.

TRIAL REGISTRATION

ISRCTN16039192, prospectively registered on 08/11/2022.

Positive Point-of-Care Influenza Test Significantly Decreases the Probability of Antibiotic Treatment during Respiratory Tract Infections in Primary Care

This study aimed to analyse clinical and laboratory findings in primary care patients with respiratory tract infections to distinguish the group more likely to receive antibiotic treatment. The study group consisted of 631 patients (264 males; 367 females) with a median age of 48 years (IQR 36-63 years). Analysed groups included patients treated with antibiotics (n = 269 patients; 43%) and those who recovered without antibiotic treatment (n = 362 patients; 57%). Patients receiving antibiotics were older (median 51 vs. 47 years; p = 0.008) and more commonly developed fever (77% vs. 25%, p < 0.0001) and cough (63% vs. 30%; p = 0.0014). Moreover, they more frequently presented wheezing and crackles upon physical examination (28% vs. 4% and 9% vs. 0.3%; p < 0.0001 and p < 0.0001, respectively). They also had more comorbidities and came to more follow-up visits (median of 4 vs. 3 and 2 vs. 1, p < 0.0001 and p < 0.0001, respectively). Patients receiving symptomatic therapy more often had positive point-of-care tests (POCTS)-20% vs. 7%; p = <0.0001. Multivariate analysis in our cohort found comorbidities complexity (odds ratio-OR 2.62; 95% confidence interval-1.54-4.46), fever (OR 32.59; 95%CI 19.15-55.47), crackles (OR 26.35; 95%CI 2.77-250.81) and the number of visits (OR 4.15; 95%CI 2.39-7.20) as factors increasing the probability of antibiotic treatment. Positive influenza POCTS reduced the risk of antibiotic therapy (OR 0.0015; 95%CI 0.0001-0.0168).

Respiratory antibacterial prescribing in primary care and the COVID-19 pandemic in England, winter season 2020-21

BACKGROUND

Antibacterial prescribing for respiratory tract infections (RTIs) accounts for almost half of all prescribing in primary care. Nearly a quarter of antibacterial prescribing in primary care is estimated to be inappropriate, the greatest being for RTIs. The COVID-19 pandemic has changed the provision of healthcare services and impacted the levels of antibacterials prescribed.

OBJECTIVES

To describe the changes in community antibacterial prescribing for RTIs in winter 2020-21 in England.

METHODS

RTI antibacterial prescribing was measured in prescription items/1000 population for primary care from January 2014 and in DDDs/1000 population/day for the totality of RTI prescribing [combined with Accident & Emergency (A&E) in secondary care], from January 2016 to February 2021. Trends were assessed using negative binomial regression and seasonally adjusted interrupted time-series analysis.

RESULTS

Antibacterials prescribed for RTIs reduced by a further 12.4% per season compared with pre-COVID (P < 0.001). In winter 2020-21, RTI prescriptions almost halved compared with the previous winter in 2019-20 (P < 0.001). The trend observed for total RTI prescribing (primary care with A&E) was similar to that observed in the community alone.

CONCLUSIONS

During COVID-19, RTI prescribing reduced in the community and the expected rise in winter was not seen in 2020-21. We found no evidence that RTI prescribing shifted from primary care to A&E in secondary care. The most likely explanation is a decrease in RTIs and presentations to primary care associated with national prevention measures for COVID-19.