Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial

Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection

Improving management of patients with acute cough by C-reactive protein point of care testing and communication training (IMPAC(3)T): study protocol of a cluster randomised controlled trial

BACKGROUND: Most antibiotic prescriptions for acute cough due to lower respiratory tract infections (LRTI) in primary care are not warranted. Diagnostic uncertainty and patient expectations and worries are major drivers of unnecessary antibiotic prescribing. A C-reactive protein (CRP) point of care test may help GPs to better guide antibiotic treatment by ruling out pneumonia in cases of low test results. Alternatively, enhanced communication skills training to help clinicians address patients' expectations and worries could lead to a decrease in antibiotic prescribing, without compromising clinical recovery, while enhancing patient enablement. The aim of this paper is to describe the design and methods of a study to assess two interventions for improving LRTI management in general practice. METHODS/DESIGN: This cluster randomised controlled, factorial trial will introduce two interventions in general practice; point of care CRP testing and enhanced communication skills training for LRTI. Twenty general practices with two participating GPs per practice will recruit 400 patients with LRTI during two winter periods. Patients will be followed up for at least 28 days. The primary outcome measure is the antibiotic prescribing rate. Secondary outcomes are clinical recovery, cost-effectiveness, use of other diagnostic tests and medical services (including reconsultation), and patient enablement. DISCUSSION: This trial is the first cluster randomised trial to evaluate the influence of point of care CRP testing in the hands of the general practitioner and enhanced communication skills, on the management of LRTI in primary care. The pragmatic nature of the study, which leaves treatment decisions up to the responsible clinicians, will enhance the applicability and generalisability of findings. The factorial design will allow conclusion to be made about the value of CRP testing on its own, communication skills training on its own, and the two combined. Evaluating a biomedical and communication based intervention ('hard' and 'soft' technologies) together in this way makes this trial unique in its field

Diagnostic properties of C-reactive protein for detecting pneumonia in children

SummaryBackgroundThe diagnostic value of C-reactive protein (CRP) level for pneumonia in children is unknown. As a first step in the assessment of the value of CRP, a diagnostic study was performed in children at an emergency department (ED).MethodsIn this cross-sectional study, data were retrospectively collected from children presenting with suspected pneumonia at the ED of Antonius Hospital Nieuwegein in The Netherlands between January 2007 and January 2012. Diagnostic outcome was pneumonia yes/no according to independent radiologist. (Un)adjusted association between CRP level and pneumonia and diagnostic value of CRP were calculated.ResultsOf 687 presenting children, 286 underwent both CRP measurement and chest radiography. 148 had pneumonia (52%). The proportion of pneumonia increased with CRP level. Negative predictive values declined, but positive predictive values increased with higher CRP thresholds. Univariable odds ratio for the association between CRP level and pneumonia was 1.2 (95% CI 1.11–1.21) per 10 mg/L increase. After adjustment for baseline characteristics CRP level remained associated with pneumonia.ConclusionsCRP level has independent diagnostic value for pneumonia in children presenting at the ED with suspected pneumonia, but low levels do not exclude pneumonia in this setting. These results prompt evaluation of CRP in primary care children with LRTI

External validation of prediction models for pneumonia in primary care patients with lower respiratory tract infection: an individual patient data meta-analysis

Pneumonia remains difficult to diagnose in primary care. Prediction models based on signs and symptoms (S&S) serve to minimize the diagnostic uncertainty. External validation of these models is essential before implementation into routine practice. In this study all published S&S models for prediction of pneumonia in primary care were externally validated in the individual patient data (IPD) of previously performed diagnostic studies

Ancient coastlines of the Black Sea and conditions for human presence – Black Sea expedition 2011

Project DO 02-337, an expedition on the RV Akademik, took place during June 2011 with financial support from the Bulgarian Science Fund. The location for this expedition was the Western Black Sea. 17 core and 8 grapple organic seabed samples were taken. The initial core samples were extracted from the submerged shorelines with subsequent ones taken from deeper water. So submerged shoreline was mapped, samples for dating, isotope analysis and pollen sampling were taken.Проект ДО 02-337, експедиція у східну частину Чорного моря на н/с «Академік» відбулася в червні 2011 року за фінансової підтримки Болгарського наукового фонду. Відібрано 17 проб трубкою і 8 проб драгою. Зразки відбиралися із затопленої берегової лінії, відібрано зразки для датування, ізотопного і пилкового аналізів.Проект ДО 02-337, экспедиция в восточную часть Черного моря на н/с «Академик» состоялась в июне 2011 г. при финансовой поддержке Болгарского научного фонда. Отобраны 17 проб трубкой и 8 проб драгой. Образцы отбирались из затопленной береговой линии, отобраны образцы для датирования, изотопного и пыльцевого анализов

New clinical prediction model for early recognition of sepsis in adult primary care patients:a prospective diagnostic cohort study of development and external validation

Background Recognising patients who need immediate hospital treatment for sepsis while simultaneously limiting unnecessary referrals is challenging for GPs.Aim To develop and validate a sepsis prediction model for adult patients in primary care.Design and setting This was a prospective cohort study in four out-of-hours primary care services in the Netherlands, conducted between June 2018 and March 2020.Method Adult patients who were acutely ill and received home visits were included. A total of nine clinical variables were selected as candidate predictors, next to the biomarkers C-reactive protein, procalcitonin, and lactate. The primary endpoint was sepsis within 72 hours of inclusion, as established by an expert panel. Multivariable logistic regression with backwards selection was used to design an optimal model with continuous clinical variables. The added value of the biomarkers was evaluated. Subsequently, a simple model using single cut-off points of continuous variables was developed and externally validated in two emergency department populations.Results A total of 357 patients were included with a median age of 80 years (interquartile range 71–86), of which 151 (42%) were diagnosed with sepsis. A model based on a simple count of one point for each of six variables (aged >65 years; temperature >38°C; systolic blood pressure ≤110 mmHg; heart rate >110/min; saturation ≤95%; and altered mental status) had good discrimination and calibration (C-statistic of 0.80 [95% confidence interval = 0.75 to 0.84]; Brier score 0.175). Biomarkers did not improve the performance of the model and were therefore not included. The model was robust during external validation.Conclusion Based on this study’s GP out-of-hours population, a simple model can accurately predict sepsis in acutely ill adult patients using readily available clinical parameters

Recognition of sepsis in primary care: a survey among GPs

Background: Early recognition and treatment of sepsis are important to reduce morbidity and mortality. Screening tools using vital signs are effective in emergency departments. It is not known how the decision to refer a patient to the hospital with a possible serious infection is made in primary care. Aim: To gain insight into the clinical decision-making process of GPs in patients with possible sepsis infections. Design & setting: Survey among a random sample of 800 GPs in the Netherlands. Method: Quantitative questionnaire using Likert scales. Results: One hundred and sixty (20.3%) of questionnaires were eligible for analysis. Based on self-reported cases of possible serious infections, the factors most often indicated as important for the decision to refer patients to the hospital were: general appearance (94.1%), gut feeling (92.1%), history (92.0%), and physical examination (89.3%). Temperature (88.7%), heart rate (88.7%), and blood pressure (82.1%), were the most frequently measured vital signs. In general, GPs more likely referred patients in case of: altered mental status (98.7%), systolic blood pressure <100 mmHg (93.7%), unable to stand (89.3%), insufficient effect of previous antibiotic treatment (87.4%), and respiratory rate ≥22/minute (86.1%). Conclusion: The GPs' assessment of patients with possible serious infection is a complex process, in which besides checking vital signs, many other aspects of the consultation guide the decision to refer a patient to the hospital. To improve care for patients with sepsis, the diagnostic and prognostic value of assessing the vital signs and symptoms, GPs' gut feeling, and additional diagnostic tests, should be prospectively studied in the primary care setting

Samenvatting van de NHG-standaard 'Acuut hoesten'

Coughing is usually caused by an uncomplicated respiratory tract infection for which antibiotics are not useful. Noscapine and codein are not advised. When the risk of complications is increased (because of age or relevant comorbidity), the decision to prescribe an antibiotic is based on the clinical presentation and any necessary additional investigations. Determination of the CRP value can assist in differentiating between pneumonia and a mild lower respiratory tract infection in moderately sick adults with several general and/or local symptoms. Patients with pneumonia should be prescribed antibiotics. Because of increasing resistance to doxycycline and macrolides, amoxicillin is the drug of first choice, and doxycycline of second choice. In the case of increased risk of severe pneumonia due to Coxiella burnetii (Q-fever) or Legionella, doxycycline remains first choice. In the case of whooping cough, additional investigation is advised if there are infants or third trimester pregnant women in the immediate environment. In moderately severe croup a single dose of glucocorticoids should be given; children with severe croup should be referred to a paediatricia