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CRP-guided antibiotic treatment in acute exacerbations of COPD admitted to hospital

Eur J Resp J 2019:53;1802014

A patient with COPD will experience an average of 1.5 exacerbations a year, and coinfection of viruses and bacteria is detected in 25% of exacerbations. Although molecular techniques can detect viral infections as triggers of an acute exacerbation, no infectious agents can be detected in around one-third of instances.

Current GOLD recommendations state that antibiotic treatment should be based on patient-reported sputum purulence, the (controversial) assumptions being that patients’ assessment of sputum colour is reliable and that purulence is a good marker of bacterial infection. As a consequence, implementation of GOLD strategy results in overuse of antibiotics, with resulting higher medical costs, side-effects and growth in antimicrobial resistance.

A 30% reduction in resistance can be achieved by implementing recommendations that discourage antibiotic treatment, for which a better marker of patients who would benefit is essential. Serum C-Reactive Protein (CRP) is such an acute-phase protein and marker for systemic inflammation, whose levels are significantly higher during an acute exacerbation of COPD compared with baseline levels. As previous reports have indicated that patients with an acute exacerbation admitted to hospital with a CRP ≥50mg/L showed a trend to benefit more from antibiotics than patients with low CRP, Prins and colleagues set out to test the hypothesis that CRP-guided antibiotic therapy may lead to a reduction of antibiotic therapy within 24 hours of admission compared with a strategy of patient-reported sputum purulence, in patients with an acute exacerbation admitted to hospital, without increasing the rate of treatment failures or adverse events within 30 days.

The multicentre randomised controlled open intervention clinical trial was performed in two hospitals in the Netherlands between July 2011 and February 2015. Eligible patients were randomly assigned to receive either CRP-directed antibiotic therapy or GOLD-directed antibiotic therapy. The primary endpoint was antibiotic treatment started during the first 24 hours after admission, and secondary endpoints included 30-day treatment failure rate, length of hospital stay, time to next exacerbation, difference in symptoms score, quality of life after 30 days and safety profile.

CRP-guided antibiotic therapy for patients hospitalised with acute exacerbations of COPD resulted in a 14.5% decrease of antibiotic use at admission compared with GOLD-guided antibiotic therapy. It was not associated with either an increase in adverse events or with 30-day treatment failure rates. Similar outcomes between groups were observed with regard to exacerbation recovery and time to next exacerbation.

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