HIQA urges pilot project to reduce antibiotic prescribing

The Health Information and Quality Authority has published a health technology assessment recommending that, as part of the wider effort to improve antimicrobial stewardship in Ireland, a carefully managed and monitored pilot programme of C-reactive protein point-of-care testing (CRP POCT) in primary care settings be considered by the Minister for Health.

Ireland has a high rate of antibiotic prescribing in patients presenting to primary care with acute respiratory tract infections (RTIs). Inappropriate antibiotic consumption is associated with increased antimicrobial resistance, causing increased illness and death from bacterial infections.

CRP POCT is used to measure the level of C-reactive protein in a person’s blood, which can be used as an indicator of bacterial infection. Clinical trials have demonstrated that the use of CRP POCT in primary care settings to inform antibiotic prescribing for acute RTIs leads to a significant reduction in antibiotic prescribing without compromising patient safety.

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HIQA’s Chief Scientist, Dr Conor Teljeur, said: ‘The use of CRP POCT in primary care settings to inform antibiotic prescribing for acute respiratory tract infections may lead to a significant reduction in antibiotic prescribing without compromising patient safety. The adoption of CRP POCT would also have organisational implications for general practices in terms of impact on patient flow, the need for quality assurance, and potential displacement of activity through longer consultation times for patients who undergo the test.’

An estimated 2.4 million prescriptions are issued for respiratory tract infections in Ireland each year – a number, which HIQA says could be halved if GPs used CRP POCT and were also provided with training directed at facilitating conversations with their patients about appropriate antibiotic prescribing.

Dr Teljeur said, “We need to determine how best to maintain the positive effects of CRP POCT over the longer term. A carefully managed and monitored pilot programme or partial roll-out of CRP POCT offers the best prospect to evaluate a CRP POCT programme and establish whether a national roll-out is advisable. CRP POCT should be considered within the context of a suite of initiatives to improve antimicrobial stewardship – it is essential that a multifaceted approach continues to be taken in managing antimicrobial resistance.’
The Health Technology Assessment of C-reactive protein point-of-care testing to guide antibiotic prescribing for acute respiratory tract infections in primary care settings was approved by the Board of HIQA last week and has been submitted to the Minister for Health for his consideration. The HTA is available on www.hiqa.ie

Testing could cost between €1million and €5 million over five years

Antimicrobial resistance leads to the deaths of approximately 700,000 people globally each year. Studies have shown that increased antibiotic consumption correlates with increased antibiotic resistance.

A CRP test measures the C-reactive protein levels in a blood sample. CRP is an acute-phase protein produced in response to infection or tissue inflammation. Raised concentrations of CRP often occur in bacterial infections, while typically only minor elevations are observed in viral infections.

Most antibiotics are prescribed in primary care settings and frequently to treat respiratory tract infections, which account for approximately one quarter of primary care attendances.
The objective of C-reactive protein point-of-care testing (CRP POCT) is to assist the clinician in ruling out serious bacterial infection, thereby supporting a decision not to prescribe an antibiotic to those who are unlikely to benefit from treatment. Clinical trials have demonstrated that the use of CRP POCT in primary care settings to inform antibiotic prescribing for acute respiratory tract infections leads to a significant reduction in antibiotic prescribing without compromising patient safety.

The clinical effectiveness of CRP POCT is not clearly explained by the results of the analysis of diagnostic test accuracy. It is likely that the impact of CRP POCT is related to how it facilitates communication between the clinician and the patient.

The use of CRP POCT does not lead to an increase in adverse effects (such as mortality, hospitalisations, or reconsultations).

If the uptake and use of CRP POCT is sustained, the five-year budget impact is approximately €1 million if combined with enhanced communication skills training, or €5 million if introduced without the training. The five-year budget impact will increase by between €8 million and €54 million if fee-per-item reimbursement is applied.