Very recently results of the EU-financed project known as the HAPPY AUDIT ("Health Alliance for Prudent Prescribing, Yield And Use of antimicrobial Drugs In the Treatment of Respiratory Tract Infections") were presented at the World Association of Family Doctors European Conference in Malaga. The study, which took place in the winter of 2008/2009 in Denmark, Sweden, Lithuania, Russia, Spain and Argentina and involved more than 600 general practitioners (GPs), was aimed to demonstrate whether improvements in the treatment of respiratory tract infections could be implemented via improved diagnostic procedures in primary care.
The overall study objective was to strengthen the surveillance of respiratory tract infections in primary healthcare through development of a multifaceted intervention programme targeting GPs, parents of young children and healthy adults. The incidence of respiratory tract infections among patients in general practice was measured and research was undertaken to explore the utility of improved diagnostic tools in patients with suspected respiratory tract infections. In addition, the study assessed whether the occurrence of bacterial resistance could be lowered by reducing the prescription of unnecessary antibiotics for such infections, many of which are of viral origin and non-responsive to treatment with conventional antibiotics.
A key parameter offered to participating doctors was an Axis-Shield's CRP (C-Reactive Protein) test (NycoCard® CRP). The use of CRP testing in Northern Europe and Switzerland to differentiate between bacterial and viral infections in primary care is widespread and this has contributed to a traditionally restricted use of antibiotics and a low rate of antibiotic resistance. In the Baltic States, Russia and Southern Europe, where CRP usage is minimal, the prescription rate of antibiotics is much higher with a high prevalence of pneumococci resistant to penicillin as one of the consequences.
Overall, a relative reduction of 25% in the participating doctors' total prescribing of antibiotics was observed. In Russia the reduction was more than 50%, and close to the same result was seen in Lithuania. In Spain prescriptions for antibiotics were reduced by one third and by 20% in Argentina. In Denmark and Sweden the reductions were 9% and 10% respectively, reflecting the fact that antibiotic resistance is lower in the Nordic countries where there is a much higher prevalence of CRP testing in primary care compared to the other countries involved in the study. In both acute sinusitis and bronchitis there was a clear association between the level of CRP and the prescribing of antibiotics and where CRP testing was not performed, significant numbers of patients received antibiotics which may not have been necessary. The full findings of the study are available from www.happyaudit.org.
The utility of CRP was further supported in a May 2009 article in the BMJ in which Jochen Cals and colleagues, based in Maastricht in the Netherlands, described a cluster-randomised, controlled clinical trial in the treatment of suspected lower respiratory tract infections in 20 Dutch general practices. It was found, inter alia, that those patients in the group which was required to be positive for elevated C-Reactive Protein (CRP), using Axis-Shield's test, before being given antibiotics, received significantly less medication compared to the control group, with equal rates of patient recovery. In the CRP group, 31% of patients received antibiotic treatment compared to 53% in the control group. The authors conclude that "general practitioners" use of point-of-care testing for C-Reactive Protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients' recovery and satisfaction with care. A combination of the illness and disease-focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care." In the discussion the authors believe "C-Reactive Protein may contribute to safely withholding antibiotics from most people with low C-Reactive Protein values who most probably would not benefit from antibiotic treatment' (BMJ 2009; 338:1374 5 May 2009).
The Axis-Shield Afinion™ analyser is very convenient to use and provides a CRP result within 3 minutes of the taking of a fingerstick blood sample. If the CRP level is low the patient is unlikely to have a bacterial infection and thus there is little point in prescribing antibiotics.
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