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Gold, incentives and meh

GPs to test patients' blood before prescribing antibiotics in pilot scheme

GPs in Manchester will be giving patients C-reactive protein blood tests to decide whether they should be prescribed antibiotics or not, under a scheme being monitored by Public Health England.

Patients who go to the GP with a respiratory infection in NHS Heywood, Middleton and Rochdale CCG will be given a finger prick blood test to assess levels of CRP, with a low level potentially ruling out a serious infection, avoiding the need for an antibiotic prescription. 

This follows the launch of a Public Health England campaign cautioning patients against pressuring their GP into prescribing antibiotics and a letter to GPs from England’s chief medical officer Professor Dame Sally Davies warning that resistance to antibiotics ‘is a very real threat that patients are facing today’. 

Research in to the test, which can give results within minutes, has found that CRP testing can cut the number of antibiotic prescriptions by up to 10 million and save the NHS £56m a year.

The test was included in NICE guidance in 2014 for diagnosing pneumonia in adults but GP leaders have said CRP testing should be restricted to cases where GPs 'would otherwise have prescribed'.

Dr Andrew Green, GPC's clinical and prescribing policy lead, said: 'We have to restrict its use to those cases where we would otherwise have prescribed, if near patient testing is used indiscriminately it might actually increase prescribing, and this will be exacerbated if the prospect of testing acts as a magnet to attract patients to our surgeries who otherwise would have self-cared.'

He added that it is of the 'utmost importance' that antibiotic prescribing be reduced with CRP testing 'likely to become more common in an effort to achieve this' but he added that practices have to be properly supported if it is to be successful.

The scheme in NHS Heywood, Middleton and Rochdale CCG was initially piloted across seven practices in the area over a year.

According to CCG board papers, the GPs involved in the pilot said that while the blood test took three minutes of consultation time, ‘the results were extremely useful to the GP and patient’ and it enabled GPs to provide ‘reassurance that refusal of a prescription was informed by best practice’. 

The rollout, which has a budget of £50,000, will see the CCG providing all 28 practices in the area with a CRP testing machine, test strips and lancets as well as training for ‘as many members of the practice as deemed to be required’.

Dr Keith Pearson, head of medicines optimisation at NHS Heywood, Middleton and Rochdale CCG, said the testing will help patients ensure that antibiotics ‘are prescribed for those patients who really need them’.

He added: ‘It’s estimated that 5,000 deaths are caused every year in England because antibiotics no longer work for some infections – 13 people every day. That’s why it’s so important for us to slow antibiotic resistance.’

The CCG told Pulse that PHE is aware of the CRP testing programme and monitoring it while it is still in the early stages.

Asked whether they were considering the scheme for a national rollout, Dr Susan Hopkins, lead healthcare epidemiologist for PHE's antimicrobial resistance programme said: 'This approach is one recommended by NICE in their guidance for patients presenting in primary care with symptoms of respiratory tract infection.

'PHE monitors antibiotic use for every clinical commissioning group and are happy to work with any CCG who are using finger-prick testing to assess levels of C-reactive protein as a way of avoiding the need for an antibiotic prescription.'

Readers' comments (24)

  • National Hopeless Service

    At last, but I suspect if it goes national dearest GPs will be paying for the CRP testing kits.

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  • looked at using it - evidence doesnt add up for startes

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  • Insufficient evidence, and no mention of CRP lag phase and what to do if crp is not raised yet still serious infection.

    Only useful in those you wouldn't have prescribed anyway.

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  • its useful when its negative to persuade resistant patients that they dont need an antibiotic..... Ive overcome a few this way and now they trust my clinical judgment

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  • This scheme concerns me. Used perfectly it will be helpful, but used in place of clinical judgement it has the potential to cause serious harm. As Anon-locum 10:33 has written - what about CRP lag?

    I cannot forget the case of a teenager who I treated for septic shock due to a lower respiratory tract infection. His CRP was just 15.

    How many courses of antibiotics do we have to save to justify one person dead due to untreated sepsis?

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  • During my worst episode of acute-on-chronic sinusitis - completely unable to work or think, with mucopurulent green discharge from my left maxillary sinus, confirmed on nasendoscopy - my CRP was just 8.

    Yet antimicrobial guidance is clear that antibiotics are a reasonable option for cases like me. (Yes, after trying nasal steroid and sinus rinse).

    Maybe it's just regression to the mean, but i have a feeling that the antibiotic got me back functioning again, a bit quicker than I otherwise would have done. And I'm a sceptic about antibiotics generally, and angst about the "damage to my microbiome" that it did.

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  • It’s a cheap finger prick test. £3.50 ish.
    Doctors should have the access.
    Probably more help for our triage nurses.
    Also reassuring when the possibility of “sepsis” is raised.

    I put this forwards as a proposal in my CCG but nothing became of it, the chair go so hacked off with it keep coming back with no action by the CCG it was dropped last month.

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  • CRP isn't cut and dry, and requires far too much nuance for triage/screening purposes. It's more useful as a monitoring tool than a diagnostic one. As mentioned before, there's the important lag phase, particularly crucial in moribund young people, and also the misconception that severity of clinical condition correlates with the degree of CRP rise. CRP does still rise with viral infections, as anyone who's worked in A&E in flu season knows. Where perception of a 'positive' CRP is 5 or 10 dependening on where you work, some studies show that 35% of patients with proven viral illness demonstrate a CRP rise 20.

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  • doctordog.

    We were discussing this 30 years ago.
    Difficult to believe a better test hasn’t been invented.

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  • We use it in practice and it is really helpful, it isn’t used instead of clinical acumen but as an adjunct. As with all of medicine, it is only one part of the jigsaw but helps to build a picture and on the ground is a great addition to the arsenal we have.

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  • Vinci Ho

    Probably overdue.
    History and examination should predominate still.
    The lagging period for CRP to rise is important to note for suspected sepsis . Philosophy is always maintaining index of suspicion, things may not be what they seem.
    Pricking an adult with near patient testing is straight forward. Pricking a child is a bit more tricky.
    Some European countries have been adopting this practice long time .
    We need the actual investment(new money) to buy the machines , test kits as well as cost of maintenance .

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  • How do you use CRP to determine if bacterial or viral?

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  • David Banner

    Some serious concerns here....
    - CRP can be raised by viruses, and not raised by bacteria. It ain't specific enough.
    - who pays for the kits?
    - patients learn there's a blood test to see if they need an abiotic, soon there will be queues round the block.
    - so you don't do CRP, and patient becomes seriously ill. Guess who they'll sue.
    - you do CRP, don't prescribe, patient becomes seriously ill, clearly you are at fault for believing a non specific blood test
    - anyone got another 3 minutes per appointment going spare? Me neither.
    - CRP rises in lots of situations, not just bacterial infections
    - "never mind your 'clinical judgement' I demand the BLOOD Test.....NOW!!!"
    - fancy pinning down a snotty 3 year old for this? The horror.....
    - in a system where patient pays, this might work. For the freebie NHS?? Nope.
    Frankly, until the boffins come up with a 99% accurate table top test that states 'virus or bacterium', then CRP surrogate marker testing is a non starter.

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  • Vinci Ho

    This may be helpful , literature wise:

    C-reactive protein as predictor of bacterial infection among patients with an influenza-like illness.
    Haran JP, et al. Am J Emerg Med. 2013.
    Show full citation

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  • Vinci Ho

    The results and conclusion :
    RESULTS: Over 3 influenza seasons there were 131 total patients analyzed (48 influenza infection, 42 other viral infection and 41 bacterial infection). CRP values were 25.65 mg/L (95% CI, 18.88-32.41) for influenza, 18.73 mg/L (95% CI, 12.97-24.49) for viral and 135.96 mg/L (95% CI, 99.38-172.54) for bacterial. There was a significant difference between the bacterial group, and both the influenza and other viral infection groups (P 80 had a specificity of 100%.

    CONCLUSION: C-reactive protein is both a sensitive and specific marker for bacterial infection in patients presenting with ILI during the influenza season.

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  • Vinci Ho

    Full citation

    Am J Emerg Med. 2013 Jan;31(1):137-44. doi: 10.1016/j.ajem.2012.06.026. Epub 2012 Aug 31.

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  • Knowledge is Porridge

    The important thing is to try it and see if it helps.
    Rather than rolling out nationwide at risk of admission registers without proper pilots...

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  • Hmmm. I remember when I did my elderly care jobs, we we’re told then not to trust CRP in the elderly as they can’t always produce an adequate inflammatory response. What happens if the CRP is normal and the patient later dies of sepsis? Will we be to blame? If not, do they need to even see a doctor?

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  • Mild rises in CRP are common in viral illnesses. .... 80 and above and Im more convinced bacterial, if it comes back 40-50ish I'll usually see them again the next day and clinically reassess. I use this in daily practice in Australia, but more so in borderline cases . Overall your judgment and tests will match up most of the time. As many contributors have stated its an adjunct and not a replacement for clinical judgment and Ive really found it helpful in cutting down antibiotic prescribing as patients believe numbers on test results more than us....it validates your clinical skills in the eye of the patients, hence helping to build their trust.... In the last 6 months I've only had to call back 2 patients on the basis of their high CRP- both were subsequently found to have bacterial infection. I have a lot fewer requests and insistence on antibiotics now, and much less conflict with patients regarding this issue. Only had one patient not return because she didnt get her antibiotics as demanded. Used sensibly as most GPs will I do feel this will help reduce un-necessary antibiotics.

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  • Vinci Ho

    Lateral thinking in grey area cases:
    Serial CRPs like cardiac enzymes in diagnosing MI(especially NSTEMI) and beta HCG in hideous ectopic pregnancy .
    Obviously, implications on cost , time and needs continuity.

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