Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

doi:10.3399/BJGP.2020.0823

Randomized Controlled Trial

. 2021 Mar 26;71(705):e266-e272.

doi: 10.3399/BJGP.2020.0823. Print 2021 Apr.

Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

David Gillespie¹, Christopher C Butler², Janine Bates³, Kerenza Hood³, Hasse Melbye⁴, Rhiannon Phillips⁵, Helen Stanton³, Mohammed Fasihul Alam⁶, Jochen Wl Cals⁷, Ann Cochrane⁸, Nigel Kirby³, Carl Llor⁹, Rachel Lowe³, Gurudutt Naik¹⁰, Evgenia Riga¹¹, Bernadette Sewell¹², Emma Thomas-Jones³, Patrick White¹³, Nick A Francis¹⁴

Affiliations

¹ Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK.
² Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
³ Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK.
⁴ General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway.
⁵ Cardiff School of Sport and Health Science, Cardiff Metropolitan University, Cardiff, UK.
⁶ Department of Public Health, College of Health Sciences, QU-Health, Qatar University, Doha, Qatar.
⁷ Department of Family Medicine, School for Public Health and Primary Care, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
⁸ York Trials Unit, Department of Health Sciences, University of York, York, UK.
⁹ Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain.
¹⁰ Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
¹¹ Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK.
¹² Swansea Centre for Health Economics, Swansea University, Swansea, UK.
¹³ School of Population Health and Environmental Sciences, King's College London, London, UK.
¹⁴ Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK.

PMID: 33657007
PMCID: PMC8007268
DOI: 10.3399/BJGP.2020.0823

Randomized Controlled Trial

Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

David Gillespie et al. Br J Gen Pract. 2021.

. 2021 Mar 26;71(705):e266-e272.

doi: 10.3399/BJGP.2020.0823. Print 2021 Apr.

Authors

Affiliations

¹ Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK.
² Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
³ Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK.
⁴ General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway.
⁵ Cardiff School of Sport and Health Science, Cardiff Metropolitan University, Cardiff, UK.
⁶ Department of Public Health, College of Health Sciences, QU-Health, Qatar University, Doha, Qatar.
⁷ Department of Family Medicine, School for Public Health and Primary Care, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
⁸ York Trials Unit, Department of Health Sciences, University of York, York, UK.
⁹ Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain.
¹⁰ Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.
¹¹ Department of Psychiatry, Medical Sciences Division, University of Oxford, Oxford, UK.
¹² Swansea Centre for Health Economics, Swansea University, Swansea, UK.
¹³ School of Population Health and Environmental Sciences, King's College London, London, UK.
¹⁴ Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK.

PMID: 33657007
PMCID: PMC8007268
DOI: 10.3399/BJGP.2020.0823

Abstract

Background: C-reactive protein (CRP) point-of-care testing can reduce antibiotic use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in primary care, without compromising patient care. Further safe reductions may be possible.

Aim: To investigate the associations between presenting features and antibiotic prescribing in patients with AECOPD in primary care.

Design and setting: Secondary analysis of a randomised controlled trial of participants presenting with AECOPD in primary care (the PACE trial).

Method: Clinicians collected participants' demographic features, comorbid illnesses, clinical signs, and symptoms. Antibiotic prescribing decisions were made after participants were randomised to receive a point-of-care CRP measurement or usual care. Multivariable regression models were fitted to explore the association between patient and clinical features and antibiotic prescribing, and extended to further explore any interactions with CRP measurement category (CRP not measured, CRP <20 mg/l, or CRP ≥20 mg/l).

Results: A total of 649 participants from 86 general practices across England and Wales were included. Odds of antibiotic prescribing were higher in the presence of clinician-recorded crackles (adjusted odds ratio [AOR] = 5.22, 95% confidence interval [CI] = 3.24 to 8.41), wheeze (AOR = 1.64, 95% CI = 1.07 to 2.52), diminished vesicular breathing (AOR = 2.95, 95% CI = 1.70 to 5.10), or clinician-reported evidence of consolidation (AOR = 34.40, 95% CI = 2.84 to 417.27). Increased age was associated with lower odds of antibiotic prescribing (AOR per additional year increase = 0.98, 95% CI = 0.95 to 1.00), as was the presence of heart failure (AOR = 0.32, 95% CI = 0.12 to 0.85).

Conclusion: Several demographic features and clinical signs and symptoms are associated with antibiotic prescribing in AECOPD. Diagnostic and prognostic value of these features may help identify further safe reductions.

Keywords: C-reactive protein; COPD; antibiotics; primary care; randomised controlled trial.

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Figures

**Figure 1.**
***Participant flow diagram.*** ***CRP = C-reactive protein. PI = principal investigator. POCT = point-of-care test.***

**Figure 2.**
***Differential association between increased sputum volume and antibiotic prescribing by CRP measurement. Vertical lines indicate 95% CIs.*** ***CI = confidence interval. CRP = C-reactive protein.***

**Figure 3.**
***Differential association between reporting crackles on auscultation and antibiotic prescribing by CRP measurement. Vertical lines indicate 95% CIs.*** ***CI = confidence interval. CRP = C-reactive protein.***

See this image and copyright information in PMC

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References

1. World Health Organization The top 10 causes of death. 2020 https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death (accessed 18 Feb 2021).
1. Nacul L, Soljak M, Samarasundera E, et al. COPD in England: a comparison of expected, model-based prevalence and observed prevalence from general practice data. J Public Health (Oxf) 2011;33(1):108–116. - PubMed
1. Harries TH, Seed PT, Jones S, et al. Chronic obstructive pulmonary disease hospital admissions and drugs — unexpected positive associations: a retrospective general practice cohort study. NPJ Prim Care Respir Med. 2014;24:14006. - PMC - PubMed
1. Llor C, Bjerrum L, Munck A, et al. Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice. Ther Adv Respir Dis. 2013;7(3):131–137. - PubMed
1. Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2007;29(6):1224–1238. - PubMed

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[1] World Health Organization The top 10 causes of death. 2020 https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death (accessed 18 Feb 2021).

[2] World Health Organization The top 10 causes of death. 2020 https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death (accessed 18 Feb 2021).

[3] Nacul L, Soljak M, Samarasundera E, et al. COPD in England: a comparison of expected, model-based prevalence and observed prevalence from general practice data. J Public Health (Oxf) 2011;33(1):108–116. - PubMed

[4] Nacul L, Soljak M, Samarasundera E, et al. COPD in England: a comparison of expected, model-based prevalence and observed prevalence from general practice data. J Public Health (Oxf) 2011;33(1):108–116. - PubMed

[5] Harries TH, Seed PT, Jones S, et al. Chronic obstructive pulmonary disease hospital admissions and drugs — unexpected positive associations: a retrospective general practice cohort study. NPJ Prim Care Respir Med. 2014;24:14006. - PMC - PubMed

[6] Harries TH, Seed PT, Jones S, et al. Chronic obstructive pulmonary disease hospital admissions and drugs — unexpected positive associations: a retrospective general practice cohort study. NPJ Prim Care Respir Med. 2014;24:14006. - PMC - PubMed

[7] Llor C, Bjerrum L, Munck A, et al. Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice. Ther Adv Respir Dis. 2013;7(3):131–137. - PubMed

[8] Llor C, Bjerrum L, Munck A, et al. Predictors for antibiotic prescribing in patients with exacerbations of COPD in general practice. Ther Adv Respir Dis. 2013;7(3):131–137. - PubMed

[9] Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2007;29(6):1224–1238. - PubMed

[10] Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J. 2007;29(6):1224–1238. - PubMed

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Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

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Associations with antibiotic prescribing for acute exacerbation of COPD in primary care: secondary analysis of a randomised controlled trial

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