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Rational use of antibiotics in primary care: What's that bug?

Antimicrobial resistance (AMR) is a global threat to public health. Waning effectiveness of anti-infective agents threaten to undermine advances in modern medicine, and reinstate infectious diseases as major causes of death in industrialised countries. Drivers of AMR are diverse and include agri- and aquaculture, environmental contamination, and of course irrational and over-use in human medicine.

Like climate change, therefore, AMR is an issue requiring action across multiple fronts. In the healthcare setting, rational prescribing is considered a key strategy for preserving the effectiveness of antibiotics by avoiding over-use. However disentangling self-limiting viral infections from antibiotic-requiring bacterial infection remains a challenge in primary care with up to half of all antibiotic prescriptions considered unnecessary, and patient expectations often swaying the balance towards irrational prescribing.

In the physicians office, therefore, clear and relatively unambiguous evidence to distinguish viral from bacterial infection could help to reduce unnecessary antibiotic prescription. One review from 2015 suggests point-of-care C-reactive protein (CRP) testing, a marker of systemic inflammation, in primary care reduces antibiotic prescription by 23-36%. CRP is routinely used in the Nordic and some other European countries.

So what is the fullness of evidence for using CRP in the primary care setting? The EUNetHTA collaboration, which focuses on producing health technology assessment reports for topics of interest across European countries, has produced a rapid assessment on C-reactive protein point-of-care testing (CRP POCT) to guide antibiotic prescribing in primary care settings for acute respiratory tract infections (RTIs) in 2019 to shine a light on this.

Using a systematic literature review, the report (among other things) addressed the question "Does the use of CRP POCT in primary care lead to a significant reduction in antibiotic prescribing without compromising patient safety?" The analysis found 12 randomised (7) and non-randomised (5) studies supporting the observation that CRP POC testing reduces antibiotic prescription, by a pooled estimate of about 25%. The report thus confirms that CRP POC testing can help to reduce antibiotic consumption, and suggests this can be achieved without affecting patient satisfaction or the rate of recovery following consultation, outcomes also examined in the report.

Interestingly, the report also asked to what extent CRP POC was reimbursed across countries. While majority (16 out of 19) countries in Europe for which data was available positively indicated CRP POC as a prescribing aid, only half (9 of 19) reimbursed the test in this indication. This means that, even though CRP POC testing is considered clinically useful and is known to reduce the rate of antibiotic prescription, many countries still do not provide a financial incentive for the uptake of the tool in the clinic. Specifically in England, funding has been identified as a key barrier for the uptake of CRP testing in primary care. A more recent analysis from 2021 surveyed 16 European countries, and found CRP testing to be reimbursed in the majority (12 countries), suggesting uptake is improving, though the sample of countries was not the same.

AMR, of course, is a global problem, and a recent paper published as part of the Lancet Commission on Diagnostics found the availability of a set of 16 diagnostic tools was available in less than 20% of primary care facilities in a selection of low/middle income countries.

In summary, accurate diagnostics can help to reduce the inappropriate use of antibiotics, a cornerstone in the fight against AMR. However despite evidence of effectiveness, CRP POC testing is still not routinely available in many countries. Increased focus on reimbursement can help to make clinically valuable tests more available in the primary care setting, thereby improving the tools available to clinicians and patients for doing their part to stem the unfolding AMR pandemic.

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