Criteria for management of RTIs in general practice with CRP POCT after proper clinical examination of the patient
| Management | Draft NICE guidance for Pneumonia49 | Dutch GP practice guideline54 | GRACE study14 | ERS51 |
|---|---|---|---|---|
| Self-limiting RTI. Do not routinely offer antibiotic therapy. Pneumonia unlikely. Give education | CRP less than 20 mg/L | CRP less than 20 mg/L | CRP less than 20 mg/L | CRP less than 20 mg/L |
| Majority of patients have self-limiting LRTI. Assessment of signs, symptoms, risk factors and CRP is important. Withhold antibiotics, in most cases | CRP 21–50 mg/L | |||
| Assessment of signs, symptoms, risk factors and CRP is crucial. Withhold antibiotics in the majority of cases and consider delayed antibiotics in the minority of cases | CRP 51–99 mg/L | |||
| Consider a delayed antibiotic prescription. Clinical presentation decisive. Prescribe antibiotics only in patients with a high risk of complications* | CRP between 20 and 100 mg/L | CRP between 20 and 100 mg/L | ||
| Severe infection. High risk of pneumonia. Offer antibiotic therapy | CRP greater than 100 mg/L | CRP greater than 100 mg/L | CRP greater than 100 mg/L | CRP greater than 100 mg/L |
*Complicated respiratory tract infection.
A complicated respiratory tract infection is an infection with an increased risk of a complicated course (mortality or hospital admission). Two groups are distinguished.
Patients with a probable diagnosis of pneumonia based on:
▸ Acute cough AND:
– Being severely ill, with for example, tachypnoea, tachycardia, hypotension (systolic blood pressure <90, diastolic blood pressure <60 mm Hg) or confusion;
– Being moderately ill and unilateral auscultatory abnormalities (however, the absence of auscultatory abnormalities does not rule out pneumonia);
– An infiltrate on chest X-ray;
– A course >7 days with fever and cough (without abnormalities on physical examination).
– For values between 20 and 100 mg/L, the clinical presentation determines policy, along with risk factors such as heart failure, diabetes mellitus, COPD, asthma, age <3 months or >75 years;
Patients with another risk factor for a complicated course.
▸ Other risk factors—particularly age and comorbidities—should also be included in the evaluation of patients with acute cough. The following factors increase risk of hospital admission and mortality:
– Age <3 months or >75 years;
– In children, cardiovascular and pulmonary conditions (except asthma);
– In adults: heart failure, severe COPD, diabetes mellitus (esp. with use of insulin), neurological conditions, severe renal insufficiency;
– A disrupted immune system (owing to oncological conditions, renal insufficiency).54
CRP, C reactive protein; COPD, chronic obstructive pulmonary disease; POCT, point-of care-test; RTI, respiratory tract infection; NICE, National Institute for Health and Care Excellence.