CRP-guided antibiotic treatment in acute exacerbations of COPD in hospital admissions

Abstract

The role of antibiotics in acute exacerbations of chronic obstructive pulmonary disease (COPD) is controversial and a biomarker identifying patients who benefit from antibiotics is mandatory. We performed a randomised, controlled trial in patients with acute exacerbations of COPD, comparing C-reactive protein (CRP)-guided antibiotic treatment to patient reported symptoms in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy, in order to show a reduction in antibiotic prescription.Patients hospitalised with acute exacerbations of COPD were randomised to receive antibiotics based either on the GOLD strategy or according to the CRP strategy (CRP ≥50 mg·L−1).In total, 101 patients were randomised to the CRP group and 119 to the GOLD group. Fewer patients in the CRP group were treated with antibiotics compared to the GOLD group (31.7% versus 46.2%, p=0.028; adjusted odds ratio (OR) 0.178, 95% CI 0.077–0.411, p=0.029). The 30-day treatment failure rate was nearly equal (44.5% in the CRP group versus 45.5% in the GOLD-group, p=0.881; adjusted OR 1.146, 95% CI 0.649–1.187, p=0.630), as was the time to next exacerbation (32 days in the CRP group versus 28 days in the GOLD group, p=0.713; adjusted hazard ratio 0.878, 95% CI 0.649–1.187, p=0.398). Length of stay was similar in both groups (7 days in the CRP group versus 6 days in the GOLD group, p=0.206). On day-30, no difference in symptom score, quality of life or serious adverse events was detected.Use of CRP as a biomarker to guide antibiotic treatment in severe acute exacerbations of COPD leads to a significant reduction in antibiotic treatment. In the present study, no differences in adverse events between both groups were found. Further research is needed for the generalisability of these findings.

Acute exacerbations of chronic obstructive pulmonary disease: in search of diagnostic biomarkers and treatable traits

“…The C-Reactive Protein Testing to Guide Antibiotic Prescribing for COPD Exacerbations (PACE) study involved 653 patients with moderate exacerbations, 70 while the CRP-guided antibiotic treatment in acute exacerbations of COPD in hospital admissions (CATCH) trial randomised 101 patients with severe exacerbations. 71 In both trials, use of CRP led to a modest decrease in antibiotics use (20.4% and 15.5% absolute decrease), without any adverse impact on the clinical outcomes. Procalcitonin-guided antibiotic administration has been evaluated in several RCTs.…”

Guiding antibiotic treatment with inflammatory biomarkers in COPD? Another brick in the wall

“…In this issue of the European Respiratory Journal, PRINS et al [8] report the result of a trial in 220 patients with acute exacerbation of COPD, comparing antibiotic usage according to a CRP-based strategy with a strategy based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Subjects assigned to the CRP group were treated with antibiotic for 7 days if CRP on admission or after 24 h was ⩾50 mg•L −1 .…”

“…In some patients, this strategy may not play out and clinical assessment and retesting is mandatory. While there was data on the use of PCT to direct antibiotic decisions from several trials, PRINS et al [8] have now provided important study results implying that CRP may also be helpful to direct treatment. While results are most convincing regarding the lowering of antibiotic exposure, proof of safety using CRP is still pending.…”

Impact of point-of-care testing for respiratory viruses on antibiotic use in adults with exacerbation of airways disease

“…[8][9][10] Patients hospitalised with exacerbation of COPD are also routinely treated with antibiotics despite viruses being frequently implicated in their aetiology 12 and a lack of high quality evidence for benefit in patients with non-life threatening exacerbations. 11 Several randomised trials of biomarker-directed therapy show that antibiotics use can be safely reduced in non-critically ill hospitalised patients with exacerbation of COPD and low levels of CRP or procalcitonin 13,14 supporting the concept that antibiotics are currently overused in this population. Diagnostic uncertainty regarding the aetiology of exacerbations of airways disease contributes to the ongoing overuse of antibiotics in these groups.…”