Adoption of C-reactive protein point-of-care tests for the management of acute childhood infections in primary care in the Netherlands and England: a comparative health systems analysis

Admission Neutrophil-to-Lymphocyte Ratio Is Superior to WBC Count at Predicting the Presence and Severity of Pediatric Musculoskeletal Infection

BACKGROUND

Accurately determining the presence and severity of pediatric musculoskeletal infection (MSKI) is crucial for effective triage and treatment. Although the white blood-cell (WBC) count is often used as a marker for MSKI, we hypothesized that the use of the WBC count is limited by age-related variability in children. We proposed that the absolute neutrophil-to-lymphocyte ratio (NLR), which has less age-related variability, is a more reliable indicator for both diagnosing and assessing the severity of MSKI. The present study aims to compare the utility of WBC against that of the NLR, as well as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), for predicting MSKI presence and severity in children.

METHODS

A retrospective cohort study was conducted with use of a database of pediatric orthopaedic consultations for suspected MSKI between January 2013 and July 2022. Diagnoses were categorized as MSKI or no infection, and the severity of any present infection was stratified as local or disseminated. Admission laboratory values were collected. Statistical modeling was performed to assess the capabilities of the WBC, NLR, CRP, and ESR to diagnose MSKI and to assess infection severity, with cutoff thresholds established for clinical use.

RESULTS

This study included 650 patients (median age, 5.2 years; 63% male; 75% White). Of these, 247 patients had no infection, while 403 were diagnosed with an MSKI. Median WBC count, NLR, CRP, and ESR were all significantly higher in pediatric cases of confirmed MSKI. WBC was a poor predictor of infection severity, whereas NLR, CRP, and ESR each positively correlated with infection severity. At the time of admission, an NLR of 4 was highly specific for detecting the presence of infection, and an NLR of 5.8 was highly specific for predicting infection dissemination. CRP was the best predictor of both infection presence and severity, demonstrating the highest specificity and sensitivity, followed by NLR, which outperformed ESR and WBC.

CONCLUSIONS

Because of considerable age-related variability, the predictive value of the WBC count for pediatric MSKI presence and severity is limited. NLR, which is less affected by age-related variability, is superior at predicting MSKI severity. Although CRP remains the benchmark, the NLR offers a valuable alternative to the WBC. Our study provides a comparative framework for these biomarkers, enhancing MSKI assessment across various clinical settings.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Utilisation and consequences of CRP point-of-care-testing in primary care practices: a real-world multicentre observational study with 1740 patient cases in Germany

BACKGROUND

C-reactive protein point-of-care tests (CRP-POCTs) can support GPs' clinical decision making but they are not widely used in German general practices.

AIM

To investigate the utilisation of semi-quantitative CRP-POCTs in routine primary care.

DESIGN & SETTING

Prospective observational study in 49 general practices in Germany (from November 2022-April 2023).

METHOD

GPs were provided with CRP-POCTs and collected data for each CRP-POCT use, with standardised data-collection sheets.

RESULTS

Data from 1740 CRP-POCT uses were recorded. GPs employed CRP-POCTs mainly for patients with respiratory tract infections (RTIs; 71.2% of all cases) and to a lesser extent for gastrointestinal infections (GIs; 10.4%). In RTIs, CRP-POCTs were frequently used to distinguish between bacterial and viral aetiology (60.8%) and to guide decisions on antibiotic prescribing (62.8%). In GIs, CRP-POCTs were mainly used to rule out severe disease progressions (53.2%) and for decisions on further diagnostic procedures (45.6%). In RTIs, CRP-POCTs influenced antibiotic prescribing in 77.5% of the cases (32.3% in favour versus 45.2% waiver). In GIs, CRP levels mainly affected decisions on further diagnostic procedures. GPs reported that CRP-POCTs were helpful in 88.6% of all cases.

CONCLUSION

When available, German GPs predominantly use semi-quantitative CRP-POCTs to guide decisions on antibiotic prescribing in patients with RTIs. CRP-POCT use improves clinical decision making and increases the GP's clinical confidence.

Procalcitonin use in febrile children attending European emergency departments: a prospective multicenter study

BACKGROUND

Studies on procalcitonin (PCT) for identifying sepsis were published as early as 1993 and since then, PCT has been the topic of over 8,500 studies. Several studies show PCT to be superior to CRP in differentiating invasive infections such as sepsis from viral infections, especially early in the disease course. However, its actual use in clinical practice is poorly documented. Our aim was to study the use of PCT in febrile children attending the ED across Europe and compare this to the use of CRP.

METHODS

The MOFICHE/PERFORM study, a prospective multicenter study, took place at 12 European EDs in eight countries and included febrile children < 18 years. In this secondary analysis of nine participating EDs that used PCT, descriptive analyses were performed, describing the use of PCT in all febrile children and for different age groups, foci of fever and fever duration.

RESULTS

In total, 31,612 pediatric febrile episodes were available for analyses. Blood tests were performed in 15,812 (50.0%, range 9.6-92.6%)) febrile episodes. CRP was included in 98.3% of blood tests (range between hospitals 80-100%), while PCT was included in only 3.9% (range 0.1-86%). PCT was most often performed in children below 3 months (12.0% versus 3.6% in older children, p < 0.001). PCT was used slightly more often in children with fever less than 24 h in comparison to children with a duration of fever ≥ 24 h (4.9% versus 3.4%, p < 0.001). Regarding clinical alarming signs, PCT was used most often in children with meningeal signs (7.0%) or a non-blanching rash (10.9%).

CONCLUSION

Actual PCT use in febrile children at European EDs is limited and varies largely between hospitals. Possible explanations include lack of guidelines, limited availability, higher costs and lack of readiness to adapt new clinical strategies.

Comparison between point-of-care testing from capillary samples and conventional laboratory testing from venous samples for white blood cells and C-reactive protein in a pediatric outpatient setting

Background

Studies on the accuracy of point-of-care (POC) testing using capillary samples are scarce. Therefore, this study aimed to assess the analytical accuracy of POC testing for white blood cell (WBC) and C-reactive protein (CRP) using capillary samples compared with conventional central laboratory testing using venous samples in a pediatric ambulatory care setting.

Methods

This was a retrospective study including patients younger than 18 years who underwent concurrent WBC and CRP evaluations via capillary and subsequent venous sampling within a 2-h window. Capillary and venous blood samples were collected using finger prick and standard venipuncture techniques, respectively. Capillary blood analysis was performed using a Microsemi CRP device. Venous samples were measured in the hospital's central laboratory. The agreement between the capillary POC and venous laboratory results was evaluated using Bland-Altman analysis.

Results

A total of 277 pediatric patients were included in this study. The median age of the participants was 1 year (interquartile range: 0-2 years). The mean difference between the capillary and venous measurements for WBC was -18 × 100/μL with 95% limits of agreement of -73 × 100/μL to 37 × 100/μL. The mean difference between the capillary and venous measurements for CRP was -0.25 mg/dL with 95% limits of agreement of -2.1 mg/dL to 1.6 mg/dL.

Conclusions

POC CRP testing via capillary sampling by finger prick demonstrated sufficient accuracy. POC CRP testing has the potential to be a valuable instrument for clinical decision making, particularly in screening febrile outpatient children.

Impact of C-reactive protein point-of-care testing on antibiotic prescriptions for children and adults with suspected respiratory tract infections in primary care: a French patient-level randomized controlled superiority trial

OBJECTIVES

The value of C-reactive protein point-of-care testing (CRP POCT) to guide antibiotic prescriptions in adults has previously been emphasized. The aim of this study was to assess the impact of CRP POCT on antibiotic prescriptions by general practitioners (GPs) for suspected lower respiratory tract infections in children ≥3 years old and in adults.

METHODS

This was an open-label randomized trial (NCT03540706) conducted in 26 GPs in France between October 2019 and March 2023. Of the 404 participating patients, 207 (51.2%) were randomized to the CRP POCT group and 197 (48.8%) to the control group (i.e. no CRP POCT). During consultations, GPs measured CRP levels in patients randomized to the CRP POCT group. The primary endpoint was the proportion of patients in each group who were prescribed antibiotics by their GP during the consultation. Z-tests were used for comparisons.

RESULTS

The overall proportion of patients treated with antibiotics was similar in the CRP POCT (n = 89/207, 43% CI: 36.2, 50.0) and in the control group (n = 94/197, 47.7% CI: 40.6, 54.9), difference: -4.7 CI: -14.4, 5.0; p 0.3. Overall, 75% of the GPs followed CRP-based antibiotic prescription recommendations in the CRP POCT group.

DISCUSSION

CRP POCT did not reduce antibiotic prescriptions in this trial.

Effect of Combination of Point-of-Care C-Reactive Protein Testing and General Practitioner Education and Long-Term Effect of Education on Reducing Antibiotic Prescribing for Children Presenting with Acute Infections in General Practice in Latvia: A Randomized Controlled Intervention Study

BACKGROUND

Antibiotics are often overprescribed in children in general practice. We investigated whether the availability of C-reactive protein point-of-care testing (CRP POCT) in daily practice and general practitioner (GP) education reduces antibiotic prescribing for children with acute infections and whether GP education has a long-term effect on antibiotic prescribing.

METHODS

This was a randomized controlled intervention study with randomization at the GP practice level. Eligible patients were children aged 1 month to 17 years presenting to general practice with an acute infection.

INTERVENTIONS

In the first study period, one GP group received combined interventions (CRP POCT was provided for daily use in combination with a live educational session), while the second GP group continued usual care. During the second study period, the GP groups were switched. During this period, the long-term education effect was evaluated in the GP group, which had previously received both interventions: the CRP POCT was no longer available in their practices in accordance with the study protocol, but education could have a lasting effect.

PRIMARY OUTCOME

Antibiotic prescribing at index consultation.

RESULTS

GP with combined intervention enrolled 1784 patients, GP with usual care enrolled 886 patients, and GP with long-term education effect enrolled 647 patients. Most of the patients had upper (76.8%) and lower (18.8%) respiratory infections. In total, 29.3% of the study patients received antibiotic prescriptions. Adjusted binary logistic regression analysis showed no differences for the primary outcome between GPs with usual care and GPs with combined intervention (aOR 0.89 (0.74-1.07), p = 0.20), but significantly lower antibiotic prescribing was observed for GPs with long-term education in comparison with GPs with usual care (aOR 0.75 (0.59-0.96), p = 0.02); however, after multilevel analyses, any differences in the antibiotic prescription between intervention groups became non-significant. GPs widely used CRP POCT when it was available in practice (for 69.1% of patients in the combined intervention group), but rarely measured CRP in the laboratory in the usual care group (8.8% (n = 78)) or long-term education group (14.8% (n = 98)). The majority of the tested patients had low CRP levels (below 20 mg/L); despite this, up to 35.4% of them received antibiotic prescriptions.

CONCLUSIONS

Our results show that the availability of CRP POCT and educational training for GPs together did not reduce antibiotic prescribing, and one-time education did not have a long-term effect on antibiotic prescribing.

C-reactive protein point-of-care testing in primary care-broader implementation needed to combat antimicrobial resistance

This study presents the perspective of an international group of experts, providing an overview of existing models and policies and guidance to facilitate a proper and sustainable implementation of C-reactive protein point-of-care testing (CRP POCT) to support antibiotic prescribing decisions for respiratory tract infections (RTIs) with the aim to tackle antimicrobial resistance (AMR). AMR threatens to render life-saving antibiotics ineffective and is already costing millions of lives and billions of Euros worldwide. AMR is strongly correlated with the volume of antibiotics used. Most antibiotics are prescribed in primary care, mostly for RTIs, and are often unnecessary. CRP POCT is an available tool and has been proven to safely and cost-effectively reduce antibiotic prescribing for RTIs in primary care. Though established in a few European countries during several years, it has still not been implemented in many European countries. Due to the complexity of inappropriate antibiotic prescribing behavior, a multifaceted approach is necessary to enable sustainable change. The effect is maximized with clear guidance, advanced communication training for primary care physicians, and delayed antibiotic prescribing strategies. CRP POCT should be included in professional guidelines and implemented together with complementary strategies. Adequate reimbursement needs to be provided, and high-quality, and primary care-friendly POCT organization and performance must be enabled. Data gathering, sharing, and discussion as incentivization for proper behaviors should be enabled. Public awareness should be increased, and healthcare professionals' awareness and understanding should be ensured. Impactful use is achieved when all stakeholders join forces to facilitate proper implementation.

Adoption of C-reactive protein rapid tests for the management of acute childhood infections in hospitals in the Netherlands and England: a comparative health systems analysis

BACKGROUND

The adoption of C-reactive protein point-of-care tests (CRP POCTs) in hospitals varies across Europe. We aimed to understand the factors that contribute to different levels of adoption of CRP POCTs for the management of acute childhood infections in two countries.

METHODS

Comparative qualitative analysis of the implementation of CRP POCTs in the Netherlands and England. The study was informed by the non-adoption, abandonment, spread, scale-up, and sustainability (NASSS) framework. Data were collected through document analysis and qualitative interviews with stakeholders. Documents were identified by a scoping literature review, search of websites, and through the stakeholders. Stakeholders were sampled purposively initially, and then by snowballing. Data were analysed thematically.

RESULTS

Forty-one documents resulted from the search and 46 interviews were conducted. Most hospital healthcare workers in the Netherlands were familiar with CRP POCTs as the tests were widely used and trusted in primary care. Moreover, although diagnostics were funded through similar Diagnosis Related Group reimbursement mechanisms in both countries, the actual funding for each hospital was more constrained in England. Compared to primary care, laboratory-based CRP tests were usually available in hospitals and their use was encouraged in both countries because they were cheaper. However, CRP POCTs were perceived as useful in some hospitals of the two countries in which the laboratory could not provide CRP measures 24/7 or within a short timeframe, and/or in emergency departments where expediting patient care was important.

CONCLUSIONS

CRP POCTs are more available in hospitals in the Netherlands because of the greater familiarity of Dutch healthcare workers with the tests which are widely used in primary care in their country and because there are more funding constraints in England. However, most hospitals in the Netherlands and England have not adopted CRP POCTs because the alternative CRP measurements from the hospital laboratory are available in a few hours and at a lower cost.