Point-of-care C-reactive protein testing and antibiotic prescribing
Authors: Thomas Althaus, Rachel C Greer, Mavuto Mukaka, Yoel Lubell
Journal: The Lancet Global Health (2020)

In our study, published in 2019 in The Lancet Global Health,1Althaus T Greer RC Swe MMM et al.Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar: an open-label, randomised, controlled trial.Lancet Glob Health. 2019; 7: e119-e131Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar we reported a modest reduction in antibiotic prescribing among febrile patients receiving primary care in Thailand and Myanmar when health-care workers had access to the results of C-reactive protein testing. In particular, compared with a control group without point-of-care testing, prescribing within the first 5 days was significantly reduced in group B, in which a threshold of 40 mg/L was used to define a high C-reactive protein concentration (adjusted odds ratio 0·80 [95% CI 0·65–0·98]). No significant difference was found between group A (20 mg/L threshold) and the control group. While carrying out secondary analyses of the data, we realised that, of the 2410 randomly allocated participants, 18 (0·7%) patients who withdrew from the study and 54 (2·2%) who were lost to follow-up were analysed as not having received an antibiotic. For participants lost to follow-up, this approach to handling missing data is legitimate; however, we should have explored other approaches to examine whether different methods would result in substantial changes to our findings. We have now re-run the analysis, excluding the data from the 18 participants who withdrew and using two alternative approaches for handling the missing data in patients lost to follow-up: first using the last observation carried forward approach, and second using an assumption that they were all subsequently prescribed an antibiotic. The differences in key outcomes between the different approaches are summarised in the appendix. Although these differences were negligible and did not materially change the findings, we appreciate the opportunity to publish these updated results to verify that the original results were robust to various approaches in handling missing data. We declare no competing interests. Download .pdf (.1 MB) Help with pdf files Supplementary appendix Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar: an open-label, randomised, controlled trialIn febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention. Full-Text PDF Open Access