Journal article

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C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations

Author(s): Butler CC, Gillespie D et al

N Engl J Med 2019; 381: 111-120

Airway diseases
Respiratory infections
General respiratory patient care

Digest Author(s): Stylianos Loukides, e-Learning Director / 13 July, 2019

The study is a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at general medical practices across England and Wales for an acute exacerbation of COPD. The pateints received either usual care mainly based on clinical assessment or usual care guided by the measurement of CRP. The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). 653 patients were randomized.The CRP-guided group reported less antibiotic use than in the usual-care group (57.0% vs. 77.4%) while the adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was −0.19 points in favor of the CRP-guided group. Furthermore, a lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%) as well as during the first 4 weeks of follow-up (59.1% vs. 79.7%). The authors finally concluded that in primary care CRP guided treatment strategy during an ECOPD resulted in fewer prescriptions of antibiotics. At the same time a clinical based beneficial effect was also reported.

Comment

Can we replace physicians' clinical assessment by the measurement of CRP? Definetely not. CRP represents an additive informative tool in terms of systemic derived inflammation. For many years guidelines have recommended the use of antibiotics for ECOPD exacerbations based on Anthonisen criteria. If we need more objective criteria like measurement of different biomarkers then the most proper approach is to combine them with the clinical derived data. At the moment is quite early to apply them in daily clinical practice.