1 / 11

Point of care tests Presentation 14.5.09, Nordisk kongress København Morten Lindbæk, professor University of Oslo and

Point of care tests Presentation 14.5.09, Nordisk kongress København Morten Lindbæk, professor University of Oslo and ASP. Outline. C-reactive protein How often used Does CRP contribute to better diagnosis? Does CRP contribute to lower antibiotic prescription?

steve
Download Presentation

Point of care tests Presentation 14.5.09, Nordisk kongress København Morten Lindbæk, professor University of Oslo and

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Point of care testsPresentation 14.5.09, Nordisk kongress KøbenhavnMorten Lindbæk, professor University of Oslo and ASP

  2. Outline • C-reactive protein • How often used • Does CRP contribute to better diagnosis? • Does CRP contribute to lower antibiotic prescription? • More use in outpatient care – nursing homes? • Strep-test • Future tests - Procalcitonin? • Does use of POC-testing contribute to medicalising self-limiting RTIs?

  3. CRP – how often used? • Norway: 1.8 mill/13 mill.(14%) of all consultations in primary care per year, started in 1990, reimbursed, now patient pays half. • Vestfold Winter 2003: 44% of all with RTIs • Sweden: 31%-41% of consultations with RTIs in general practice • Denmark: Also extensively used. • Finland: Much lower us in primary care • Holland: Little use • UK: no use in primary care • Switserland: moderate use in primary care

  4. Does CRP contribute to better diagnostic work in general practice • LRTI • Van der Meer: syst review of diagnostic value: 12 studies, heterogenous, sens 8-99%, spec 27-95% bact. infection. Conclusion: Not recommended. Much discussed • Hopstaken (Holland) demonstrated that CRP was good to single out patients with documented viral/bacterial infection, not to separate them • Melbye demonstrated that CRP was good to single out patients with bacterial pneumonia in primary care • Acute sinusitis • Jens G Hansen BMJ 1995 (Both CRP and ESR) • Lindbæk (CRP/ESR bivariate, only ESR multivariate analysis) • Tonsillitis? • Can CRP single out those Strep A patients that can profit from antibiotic treatment? Not been performed research on this

  5. Can use of CRP contribute to more rational antibiotic use in RTIs? • Acute sinusitis: • Bjerrum Doctors using CRP prescribed in 59%, without 78% • JG Hansen: RCT based on elevated CRP-level, demonstrated significant less pain, but not general condition • LRTIs: • Cals Dutch study (BMJ May 09). 2x2 factorial design with educational outreach (27% vs 54%) and use of CRP (31% vs 53%). Both gave significant lowering of prescription, 23% in combination • RTIs: • Lindbæk observational study CRP test contributed significantly to 30% of patients with infections. CRP contributed to reduction of antibiotics in 25%

  6. Other use of CRP-test in outpatient care • The use in nursing homes in Norway is increasing. Can contribute to better diagnosing of RTI’s. Especially combined with more use of intravenous antibiotics • Also more use in homebased care by nurses

  7. Can use of Strep A test contribute to more exact diagnosis? • Sensitivity 90%, specificity 95%, LR+ 16 • Combination of Centor criteria (4) and testing gives most certain diagnosis • But high rate of healthy carriers, especially among children and adolescents in summer, 20-30 % (Ronny Gunnarson)

  8. Can use of Strep A test contribute to reduced use of antibiotics? • No significant results from primary care, one smaller Danish study showed no reduction (Andersen et al BMJ 1995) • Some studies from specialist care, pediatricians in Greece

  9. New promising POC-test:Maybe procalcitonin? • METHODS: 53 Swiss primary care physicians recruited 458 patients, each patient with an acute respiratory tract infection and, in the physician's opinion, in need of antibiotics. Results after 2-4 hours from hospital • RCT: For patients randomized to procalcitonin-guided therapy or standard, the use of antibiotics was more or less strongly discouraged or recommended (cut-off >0.25 microg/L). • RESULTS: With procalcitonin-guided therapy, the antibiotic prescription rate was 72% lower (95% CI, 66%-78%) than with standard therapy. Both approaches led to a similar proportion of patients reporting symptoms of ongoing or relapsing infection at 28 days (adjusted odds ratio, 1.0 [95% CI, 0.7-1.5]).

  10. Medicalising effect of POC-testing? • Malin Andre: Question the use of CRP, 42% of all with RTI had a test performed. • Often used in URTI where the agent often is viral and the consequence is doubtful. Small reduction in ab us (44% vs 41%). Danger of medicalisation • Will use of POC-testing lead to: Patients/parents go to doctor just to be sure? • ”Table catching”: When you have taken a strep A, positive, it is harder to avoid giving antibiotics, even if the patient is feeling pretty well • Should GPs be more critical in when to use POC-tests. Reimbursement?

More Related