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C-reactive Protein as Biomarker Might Reduce

Antibiotic Use
By Will Boggs MD

November 13, 2014

NEW YORK (Reuters Health) - As a marker of systemic inflammation, C-reactive protein
(CRP) levels can be used to reduce antibiotic prescriptions for acute respiratory infections,
researchers from Denmark report in the Cochrane Database of Systematic Reviews.
"CRP is no magic wand but a tool to assist the doctor in assessing the need of antibiotics,"
Dr. Rune Aabenhus from the University of Copenhagen told Reuters Health. "It is intended to
decrease physician uncertainty more than a tool to persuade patients that antibiotic treatment
may not be necessary or beneficial."
Several biomarkers, including CRP, white blood cell count, and procalcitonin, have been
proposed as indicators of serious infection in patients who present with acute respiratory
infection symptoms.
Dr. Aabenhus and colleagues examined the evidence supporting the use of these biomarkers
as a means to reduce antibiotic prescriptions in their systematic review of six studies on the
use of CRP (involving 3284 participants with acute respiratory infections from primary care
settings). They were unable to find informative studies on the use of white blood cell count or
The pooled results of the CRP trials showed that CRP testing reduced the number of
antibiotic prescriptions for acute respiratory infections by 22%, compared with standard care.
There was considerable heterogeneity in the results, which precluded a precise estimate of
the reduction in antibiotic use in a given setting.
Comparing the use of CRP and standard care, there were no significant differences in clinical
recovery at day 7, reconsultation rates at 28 days of follow-up, number of patients with
substantial improvement at 28 days of follow-up, or number of satisfied patients, according to
the November 6th online report.
There were more hospitalizations in the CRP group than in the standard care group, but the
difference lost statistical significance after adjusting for study designs.
There were no deaths or serious complications in any of the studies.
"If the doctor after completing history taking and physical exam is certain that an antibiotic is
or is not needed, a CRP test should not be performed," Dr. Aabenhus said. "However, in case
of doubt or uncertainty, a CRP test may be performed."
"We did not directly look for an optimal CRP cut off level, but if duration of symptoms are
more than 24 hours and the CRP level is below 20 (mg/L), no benefit can be expected from
antibiotic treatment and antibiotic (can be) withheld, given alarm symptoms are discussed and
appropriate safety netting performed," he explained. "The grey zone between 21 and 99 is
more controversial, and the achievable reduction in antibiotic use is obviously very dependent

on the chosen cut off level. However, the current body of evidence does not allow for specific
conclusions re this."
"I think it is important to stress that there is still controversy regarding the cost effectiveness
and that other antibiotic saving strategies like delayed prescribing or training in
communication skills may also be effective in achieving the common goal of a reduction in
antibiotic use by limiting inappropriate prescribing," Dr. Aabenhus added.
"Also of importance is the fact that CRP does not directly distinguish between viral and
bacterial infections, as it only measures the degree of inflammation present in the blood at the
given time," Dr. Aabenhus said. "If this level is high, the risk of a serious infection increases
and the probability of a beneficial effect of antibiotics will also increase. CRP testing is thus
not a diagnostic marker but maybe more of a prognostic marker."
Cochrane Database Systematic Rev 2014.

Reuters Health Information 2014

Cite this article: C-reactive Protein as Biomarker Might Reduce Antibiotic
Use. Medscape. Nov 12, 2014.