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GPs should use point-of-care test to guide antibiotic use for pneumonia, says NICE

GPs should consider using a point-of-care test to help decide whether patients presenting with mild pneumonia need antibiotics, according to draft recommendations from NICE.

The draft guidance proposes GPs carry out the test – for C-reactive protein levels – if it is not clear from a clinical assessment whether antibiotics should be prescribed (see box).

They should then offer a five-day course of a single antibiotic in patients with low-severity pneumonia – but not a fluoroquinolone – and tell patients to come back if their symptoms do not improve within three days.

The guidance also advises GPs to use the CRB65 risk score when making a judgement about whether patients should be referred to hospital.

The CRB65 score assigns points based on aspects such as confusion, raised respiratory rate, low blood pressure and older age. NICE says GPs can consider home-based care for patients with a score of zero, but should consider hospital assessment for all other patients, particularly those with a score of two or higher.

Professor Mark Baker, NICE’s director of clinical practices, said: ‘Pneumonia can be difficult to treat; it requires careful assessment and thoughtful treatment. These new draft recommendations make it very clear how to best test for pneumonia and when to consider treating with antibiotics.’

NICE draft pneumonia guidance – C-reactive protein test

Consider a point-of-care C-reactive protein (CRP) test for patients with lower respiratory tract infection in primary care if it is not clear after clinical assessment whether antibiotics should be prescribed. Use the results of the CRP test as follows:

  • Do not routinely offer antibiotic therapy if the C-reactive protein concentration is less than 20mg/litre
  • Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C-reactive protein concentration is between 20 mg/litre and 100 mg/litre
  • Offer antibiotic therapy if the C-reactive protein concentration is greater than 100 mg/litre

This story was amended 22.40, 18 June to clarify when GPs should consider home care or hospital assessment based on the CRB65 risk score.

NICE draft guidelines - Pneumonia: diagnosis and management of community- and hospital-acquired pneumonia in adults

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Readers' comments (8)

  • Bornjovial

    And where do these point of care CRP tests exist at present? How about home visits -do we take these kits on home visits?
    CRB65 is useful to guide need for admission versus community treatment but should be taken in context of overall patient context.
    The draft guidelines state that if the CRB65 score is more than 0 then GP should consider (NOT SHOULD BE SENT) hospital assessment which means anyone with chest symptoms who is aged>65 should be considered for admission.
    That would change my consideration for acute referral (for chest infections) from few per year to >25/ year. In fact we successfully manage a good few intermediate risk patients in community with IV antibiotics via Community intervention team.
    Also choice of antibiotic on UK based guidelines are more conservative than international guidelines (CDC) on same which suggest use of Fluroquinolones as first line (for the last decade or so) -Just an observation not criticism or support.

    P.S Editor can you edit the article as the draft guidelines state -anyone with score more than zero but especially if 2 or more should considered for hospital admission and NOT SHOULD BE SENT TO HOSPITAL as noted in the article.

    Link to CDC guidelines
    http://www.thoracic.org/statements/resources/mtpi/idsaats-cap.pdf. page 3 of the 146 pages is the most important.

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  • Vinci Ho

    I think they are using this type of CRP kit in Scandinavian countries?

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  • will this be the unfunded near patient crp testing?

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  • This is also now widespread practice in the Netherlands following their participation in the GRACE study for precisely this application

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  • 80%. Cap treated by GPs in 30 years I managed these and really get more deaths in hospital . The annual 3 death Cert I do are all expected .They have no beds and people die in hospital.

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  • There are point of care CRP systems already available for GP practices in the UK. This one does HbA1c as well:
    http://www.menarinidiag.co.uk/Products/Haemoglobin-Analyser/B-analyst

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  • I am a nurse practitioner and see many patients above the age of 65 in the community. Will these CRP kits be available across all the are settings and not only Gps? Often I do request CRP test, but there is a cost to consider with normal venepuncture and not always appropriate when is Friday afternoon and u can't have the results immediately.
    I am concerned with the draft pneumonia guidance 2nd point to consider delayed antibiotic when CRP between 20 to 100. My experience is that with CRP 70 patients are already present unwell and further delay of prescribing increases the chances of hospital admission.

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  • Br J Gen Pract. 2010 Oct;60(579):e423-33.
    Validity of BTS guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis.
    McNally M1, Curtain J, O'Brien KK, Dimitrov BD, Fahey T.
    CRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice.

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