Accepted best practice guidance statements for C-reactive protein (CRP) point-of-care test (POCT) use in primary care management of lower respiratory tract infections (LRTIs) from a three-round Delphi study
| # | Statement |
| Section 1: use of the POCT (n=13) | |
| 1 | A thorough clinical assessment of the patient’s history (eg, comorbidities, previous admissions), risk profile and acute clinical situation should precede CRP POCT. |
| 2 | Validated, evidence-based clinical decision rules (eg, STARWAVe and CRB-65) should be incorporated into the clinical assessment of patients suspected of having a LRTI. |
| 3 | CRP POCT should be used for patients suspected of having a LRTI only when the prescriber is uncertain about prescribing antibiotics for LRTIs following their clinical assessment. |
| 4 | CRP POCT should aid appropriate prescribing of antibiotics for LRTIs by reducing diagnostic uncertainty as part of the clinical assessment. |
| 5 | Consent, either written or implied, should be obtained from the patient or the patient’s parent or legal guardian in the case of children below the age of 16 for their blood sample to be taken for CRP POCT. Additionally, where appropriate, children should provide their assent. |
| 6 | CRP POCT results should be interpreted with caution in patients with existing conditions that can elevate CRP values (eg, arthritis, gout, IBD) and in those receiving immunotherapy. |
| 7 | CRP POCT should be performed within general practice by general practitioners (GPs), guided by clinical judgement and current best practice guidance. |
| 8 | With appropriate training for the clinical assessment of patients suspected of having an LRTI, healthcare professionals in general practice, other than GPs themselves, should be able to obtain and interpret CRP POCT results with GP oversight. |
| 9 | With appropriate training for treating patients suspected of having an LRTI, healthcare professionals in general practice other than GPs themselves should be able to act on CRP POCT results with GP oversight. |
| 10 | CRP POCT should be used in conjunction with a rapid viral test in the presence of cough and fever during an active pandemic or epidemic. This is contingent on the tests demonstrating appropriate sensitivity, specificity and suitability for the context and population. |
| 11 | The cost of the CRP POCT device should be reimbursed by governments. |
| 12 | The cost of the CRP POCT consumables should be reimbursed by governments. |
| 13 | CRP POCT providers (ie, GPs and/or CPs) should be reimbursed by governments. |
| Section 2: the detection of bacterial LRTIs using the POCT and the provision of antibiotics (n=7) | |
| 14 | CRP values >20 mg/L may indicate the possibility of a bacterial LRTI, though clinical judgement should be used as CRP levels can also be elevated in viral infections (although CRP elevations due to viral infections typically remain below 20 mg/L). |
| 15 | CRP values <20 mg/L may indicate a self-limiting infection (bacterial/viral) for which antibiotics should not be prescribed.* |
| 16 | In cases where a child is presented early in the progression of symptoms (ie, in the first 24 hours), CRP results should be interpreted carefully, with attention to the clinical context and severity of illness. In this instance, a CRP value <5 mg/L may indicate a self-limiting infection (bacterial or viral) for which antibiotics should not be prescribed. |
| 17 | CRP values >100 mg/L in adults indicate the presence of a severe infection for which antibiotics should be prescribed following national/international antibiotic prescribing guidance and hospital referral considered.† |
| 18 | CRP values >75 mg/L in children indicate the presence of a severe infection for which antibiotics should be prescribed. following national/international antibiotic prescribing guidance and hospital referral considered.† |
| 19 | For CRP values in the range 20–100 mg/L in low-risk patients (ie, not at a higher risk of deterioration due to existing conditions or severe symptoms), prescribing of antibiotics should be avoided or delayed following national/international antibiotic prescribing guidance.* |
| 20 | For CRP values in the range 20–100 mg/L in patients with a higher risk of deterioration (ie, due to existing conditions or severe symptoms), antibiotic prescribing following national/international antibiotic prescribing guidance should be considered.† |
| Section 3: communication strategies to increase antibiotic stewardship (n=4) | |
| 21 | Patients should be informed about antibiotic resistance, the role (or lack thereof) of antibiotics in treating LRTIs and antibiotic stewardship. |
| 22 | CRP POCT results can be used to support patient-healthcare professional communication, especially when explaining whether antibiotics are required for a LRTI. |
| 23 | For CRP POCT conducted in community pharmacies, patients should be provided with a detailed description of the assessment undertaken and the results obtained so they can provide these to their GP if necessary. |
| 24 | CRP POCT should be used together with enhanced communication skills training. |
| Section 4: features and performance of the point-of-care device (n=9) | |
| 25 | CRP POCT results should have a high sensitivity. |
| 26 | CRP POCT results should have a high specificity. |
| 27 | CRP POCT results should have a high positive predictive value. |
| 28 | CRP POCT results should have a high negative predictive value. |
| 29 | Detection of a possible bacterial LRTI directly from a patient’s blood sample using CRP POCT should be completed in a one-step process. |
| 30 | CRP POCT should require a small sample volume of blood. |
| 31 | The space required for the CRP POCT device and operation should be minimal. |
| 32 | Results should be stored on the CRP POCT device or the PMR, with consideration for ease of use and integration into clinical workflow, while ensuring patient privacy and data security. |
| 33 | CRP POCT results should be automatically transferred from the device to patients’ records where feasible and efficient, leveraging fully integrated electronic healthcare records or easily scannable formats, to streamline documentation and ensure accurate record-keeping. |
| Section 5: user operation of the POCT (n=4) | |
| 34 | CRP POCT providers (eg, GPs, CPs and advanced nurse practitioners) should undergo training to use the POCT device and to interpret CRP results, combined with enhanced communication skills training to effectively convey findings and implications to patients. |
| 35 | The time required by staff to run the CRP POCT should be minimal. |
| 36 | Staff operation of the CRP POCT should follow the steps outlined by the manufacturer of the POCT device being used. |
| 37 | Maintenance, calibration and quality control will be required for the CRP POCT device as per manufacturer recommendations, with support and oversight provided by device supplier. |
*Though clinical judgement and patient-specific factors should be considered, with clear communication of self-care and re-referral advice to the patient.
†Alongside thorough clinical assessment, with attention to the clinical context, severity of illness and potential non-bacterial causes of elevated CRP levels.
CP, community pharmacist; IBD, inflammatory bowel disease; PMR, patient medication record.