Using Point-of-care C-reactive protein to guide Antibiotic prescribing for Respiratory tract infections in Elderly nursing home residents (UPCARE) (WC2017-001)

Background

Starting date: 15/05/2017

Antibiotics are among the most commonly prescribed drugs in nursing homes (NHs), with 47% to 79% of the residents receiving at least one antibiotic course annually. In a concluded study (IMPACT), it was shown that almost 25% of these prescriptions were not required at the index consultation. Inappropriate antibiotic use is undesirable both on the patient level, considering their exposure to side-effects and drug interactions, and on the societal level, given the potential development of antibiotic resistance.

About one-third of the antibiotic prescriptions in Dutch NHs are for treatment of suspected lower respiratory tract infections (LRTI). Diagnosing LRTI is challenging in this setting , as NH residents often lack typical symptoms. Also, cognitive disabilities can impede communication of experienced complaints. ln addition, X-ray, bacterial culture and laboratory research are often not well-applicable in the vulnerable NH population or not directly available in this setting. Diagnostic uncertainty can result in AB prescribing to be 'better safe than sorry', an attitude towards antibiotic prescribing that can be further enforced by a variety of external factors, such as expectations of patients, family members and nursing staff . Together, these factors increase the chance of unnecessary antibiotic prescribing for NH residents.

The use of biomarker C-reactive protein (CRP) - an indicator of presence and severity of inflammation - can improve the evaluation of LRTI. Several studies demonstrated that adding CRP values to the evaluation of clinical signs and symptoms indeed improves the reliability of the diagnosis pneumonia. CRP point-of-care testing (POCT) may therefore be a promising tool to reduce unnecessary antibiotic use for LRTI in NHs. With CRP POCT, capillary blood tests are performed with test results available within minutes. A Dutch cluster RCT showed a significant reduction in antibiotic use for LRTI in general practice patients where CRP POCT was applied (31% AB use), compared to a control group (53% AB use). There were no negative influences on clinical recovery, and the intervention appeared cost-effective. To our best knowledge, the  effectiveness of CRP POCT on antibiotic prescribing has hitherto not been investigated in NHs.