The Value of C-reactive Protein in Primary Health Care

Transcription

The Value of C-reactive Protein in Primary Health Care
POC
The Value of C-reactive Protein
in Primary Health Care
2
POC
The Value of C-reactive Protein
in Primary Health Care
3
Disclaimer
This booklet is intended to provide health care practitioners with an overview of QuikRead CRP, a rapid C-reactive
protein assay, its diagnostic potential and value in routine primary care practice.
Although every effort has been made to provide accurate information, Orion Diagnostica accepts no responsibility whatsoever for the accuracy, correctness or completeness of the information contained in this booklet. It is
the responsibility of the health care practitioner to evaluate the contents of this booklet and to verify the information presented. The ultimate judgement regarding the care and appropriate treatment of a particular individual
must always be made by the health care practitioner in the light of all the clinical information available about the
individual.
Orion Diagnostica therefore accepts no liability for any injury or damage to person or property resulting from
acceptance of the information in this booklet. Hence, liability claims regarding possible injury or damage will be
rejected.
The information in this booklet may contain references to products that are not available or approved by the
regulatory authorities in your country. Orion Diagnostica assumes no responsibility for you accessing information
that may not comply with legislation, regulations or usage applicable in your country. You are advised to consult
Orion Diagnostica’s local business contact or marketing partner for information about the availability of Orion
Diagnostica products in your country.
4
Contents
Introduction................................................................................... 7
Antibiotic use and resistance.......................................................... 8
Antibiotic resistance on the rise......................................................................... 8
Development of new antibiotics on the decline.................................................. 9
Variation in antibiotic use and antibiotic resistance among countries................ 10
C-reactive protein (CRP)............................................................... 11
CRP in distinguishing between bacterial and viral infections............................. 11
CRP in monitoring the efficacy of antibiotic therapy......................................... 12
CRP versus erythrocyte sedimentation rate (ESR).............................................. 13
CRP versus white blood cell count (WBC)......................................................... 13
CRP versus procalcitonin (PCT)......................................................................... 13
CRP is a good servant...................................................................................... 13
QuikRead CRP guides the use of antibiotics.................................. 14
Diagnostic dilemma......................................................................................... 14
QuikRead CRP................................................................................................. 14
Interpreting the QuikRead CRP test result..................................... 16
QuikRead CRP in various clinical situations................................... 17
Serious bacterial infections.............................................................................. 18
Acute respiratory tract infections..................................................................... 18
Upper respiratory tract infections.............................................................. 19
Common cold..................................................................................... 19
Acute sinusitis..................................................................................... 19
Acute pharyngitis................................................................................ 19
Acute otitis media............................................................................... 20
Lower respiratory tract infections.............................................................. 20
Acute bronchitis................................................................................. 20
Community-acquired pneumonia........................................................ 21
Urinary tract infections.................................................................................... 22
QuikRead CRP in the routine diagnosis of
acute respiratory tract infection.................................................... 23
References................................................................................... 26
5
6
Introduction
This booklet is intended to give primary care practitioners an overview of
QuikRead® CRP, a rapid C-reactive protein (CRP) assay, its diagnostic potential and value in routine practice. The emphasis is on situations in which
an immediately available, quantitative CRP result can help to make adequate
and timely diagnostic and treatment decisions.
CRP is a protein normally present in very low concentrations in the
blood of healthy people. In bacterial infections, CRP concentrations markedly increase, whereas viral infections usually only induce very modest CRP
elevation or none at all.
In primary care, a large proportion of antibiotics is prescribed to treat
conditions in which antibiotics are of little or no benefit. Excessive and
inappropriate use of antibiotics, leading to the emergence of increasingly
resistant bacteria, has become a severe problem worldwide. Against this
background, the individual health care practitioner often faces the dilemma
of how to identify patients who need – and particularly those who do not
need – antibiotic therapy.
QuikRead CRP is an easy-to-use test for quantitative measurement of
CRP. The test is designed to be performed on a finger-prick blood sample and
the test result is available in a couple of minutes during the patient consultation. QuikRead CRP is a valuable tool helping the primary care practitioner
to distinguish between bacterial and viral infections and to target antibiotic
treatment to patients most likely to benefit from it.
7
Antibiotic use and resistance
Antibiotics are a cornerstone for the management of bacterial infections.
Therefore, antibiotics should be used with caution and only when absolutely
necessary.
Like all medicines, antibiotics can cause side effects. The most common
side effects are generally considered to be mild, and include conditions such
as headache, dizziness, gastrointestinal upset, nausea and vomiting.1,2,3
However, antibiotics may alter the normal microbial flora of the patient
and lead to acute or even chronic disease in some individuals.4,5,6,7,8,9,10 The
effects of antibiotic treatment on the native gut microbial flora are well
established and range from self-limiting mild diarrhea to life-threatening
pseudomembranous colitis.11,12,13,14 Vaginal yeast infections are also common
after taking antibiotics.15,16,17,18 Being a cause for concern and discomfort for
many women, they may even be a reason for not wanting to take prescribed
antibiotics.15 Even a short-term antibiotic course can cause long-term alterations in the commensal microbial flora of the individual patient4,5,6,19, and
therefore unnecessary antibiotic courses should be avoided.
Antibiotics can also cause allergic reactions ranging from skin rash to
severe life-threatening attacks that require immediate medical attention.20
Other serious adverse reactions that warrant for the judicious and cautious
use of antibiotics include alterations in blood glucose levels, QTc interval
prolongation, seizures, phototoxity and tendinopathy.3,21
Recently, antibiotic use in early life has also been linked to childhood
asthma.22,23,24
Antibiotic resistance on the rise
Frequent use of antibiotics results in antibiotic resistance which is one of the
most serious public health concerns today.25–28 A strong correlation between
frequent use of antibiotics and a rising rate of antibiotic resistance has been
established in many studies (Fig. 1).27, 29–31
8
Penicilli-nonsusceptible S. pneumoniae (%)
Total antibiotic use (DDD/1,000 pop/day)
Fig. 1. Total antibiotic use in the out­patient
setting versus prevalence of penicillinnonsusceptible Streptococcus pneumoniae in
20 industrial countries. DDD = defined daily
doses.30
Antibiotic-resistant bacteria have steadily increased and present a threat to
disease management32 not only in hospitals but also in primary care.33 Many
previously effective antibiotics are now ineffective, and the appearance of
multidrug-resistant bacteria is contributing substantially to the problem.26,32–34
About 80–90% of antibiotics are prescribed within primary care27,35–37,
and as many as 50% of these prescriptions are likely to be unnecessary.33,36
Moreover, broad-spectrum antibiotics are substantially overused, even for
conditions where antibiotic therapy is not indicated at all, a practice additionally driving up resistance problems.38,39
Development of new antibiotics on the decline
Development of new antibiotics is not keeping pace with the increase of antibiotic resistance. Despite the critical need for new antibiotics, the development
of these drugs is declining.25,31,32,40 It is estimated that the development of a
new antibiotic takes 10–15 years from discovery to approval.31,41
9
Variation in antibiotic use and antibiotic resistance
among countries
The use of antibiotics in primary care differs among countries (Fig. 2), which
is unlikely to be caused by differences in frequencies of bacterial infections.42
Antibiotic-prescribing practices, attitudes towards antibiotic use and regulatory control of prescribing have been found to have an impact on the prevalence of antibiotic-resistant bacteria.28,42–45
Most antibiotic prescriptions in primary health care are for acute respiratory tract infections. Antibiotic treatment of these conditions is, however,
often inappropriate, since the vast majority have a viral cause (see Acute
respiratory tract infection, page 15). A diagnostic test providing an objective
and immediate result that confirms or rules out a viral infection could have
an important role in ensuring more precise diagnoses and reducing inappropriate use of antibiotics.
Other antibacterials (J01X)
Aminoglycosides (J01G)
Amphenicols (J01B)
35
Quinolones (J01M)
MLS (J01F)
25
Tetracyclines (J01A)
Cephalosporins (J01D)
20
Penicillins (J01C)
15
10
† = Total use; ‡ = 2005 use;
TMP = Trimethoprim; MLS = Macrolides, Lincosamides and Streptogramins
Fig. 2. Outpatient antibiotic use in 21 European countries in 2006. DDD = defined daily doses.46
10
Russia
Austria
Netherlands
Slovenia
Denmark
Sweden ‡
Hungaria
Czech Republic
Finland
Bulgaria †
Spain ‡
Iceland
Poland ‡
Ireland
Croatia
Portugal
France
Cyprus †
Greece † ‡
0
Italy
5
Belgium
DDD / 1000 inabitants / day
TMP and sulphamides (J01E)
30
C-reactive protein (CRP)
CRP is an acute-phase protein synthesised in the liver. CRP concentrations are
normally low in the blood of healthy people; 99% have levels under 10 mg/ll47
which is generally considered as the cut-off for inflammatory disease48-51 (see
also QuikRead CRP in various clinical situations, page 14).
Production of CRP is rapidly induced by cytokines in response to infection, inflammation and tissue injury.47,52,53 Elevated CRP concentrations can
be detected within 6–12 hours of the onset of an inflammatory stimulus54,55,
and the concentrations peak within 24–48 hours.47,51,56 The elevation can even
be more than 1000-fold.47,57, 58
CRP has been found to reflect closely the extent, activity and severity
of disease.47 With resolution of an infection or inflammatory process, CRP
levels decline rapidly owing to the short half-life (19 hours) of CRP in the
bloodstream.47,51
Although elevated CRP concentration is not specific to any particular
disease, quantitative measurement of CRP adds valuable information to the
diagnosis, treatment and monitoring of an inflammatory process and the
associated disease.
In a primary care setting, CRP can assist doctors in
• distinguishing between bacterial and viral infections
• monitoring the efficacy of antibiotic therapy.
CRP in distinguishing between bacterial and viral
infections
Combined with careful clinical assessment, CRP can help
to differentiate bacterial infection from viral infection.
CRP levels are increased markedly by invasive
bacterial infection. 50–85% of patients with a CRP
CRP levels
are increased
markedly by
invasive bacterial
infection.
concentration exceeding 100 mg/l will have a bacterial
infection.58–60 Acute Gram-positive and Gram-negative
11
bacterial infections are among the most potent stimuli for CRP production.47
Bacterial infection without a clearly elevated CRP concentration is unlikely but may occasionally be encountered. Patients may have low or only
moderately elevated CRP concentrations if the sample is taken during the
first 6–12 hours after onset of the infection. Therefore, a normal CRP value
on the first day of illness should be interpreted with caution.55 CRP results
should also be interpreted with great care in the early neonatal period. The
amount of CRP produced depends on the invasiveness and location of the
infection in the body. Superficial or localised, minor bacterial infection may
not stimulate CRP production significantly.47
Uncomplicated viral infection usually has little effect on CRP concentration.47 A moderately elevated CRP concentration (10–60 mg/l) may, nevertheless, be found in some upper respiratory tract infections with a peak
during days 2–4 of illness.55,61 The elevation may, however, in
some cases reflect secondary bacterial infection.47 Higher
CRP values can be found in infections caused by adenoviruses.62 In patients with signs and symptoms of common
cold, a minor part of cases are, however, associated with
adenoviruses.63-65
Uncomplicated
viral infection
usually has little
effect on CRP
concentration.
CRP in monitoring the efficacy of
antibiotic therapy
CRP concentrations drop rapidly, at roughly 50% a day51, in response to
effective treatment. Serial measurement of CRP is therefore of great value in
monitoring the effect of antibiotic therapy, and antibiotics can usually be stopped upon normalisation of the CRP value.47,51,66,67
Serial measurement
of CRP is of great
value in monitoring
the effect of
antibiotic therapy.
12
In contrast, inadequate treatment is reflected in persistently
high CRP levels which may even rise further if the infection takes a turn for the worse.47,59 Monitoring of CRP
concentration can alert to complications and predict the
outcome earlier than clinical signs.68
CRP versus erythrocyte sedimentation rate ESR
ESR is a nonspecific inflammation marker and a commonly performed
laboratory analysis.47,69 CRP has many advantages over ESR. ESR is greatly
influenced by the size, shape and number of erythrocytes, gender and age of
the patient, as well as serum proteins such as fibrinogen and immunoglobulins.
Therefore, ESR results can vary and sometimes mislead.58 As a patient’s condition worsens or improves, ESR changes rather slowly, whereas plasma CRP
concentration reacts rapidly.58,70 ESR is also greatly affected by technical factors, such as assay temperature, sample dilution and tilting of the ESR tube.69
CRP versus white blood cell count WBC
CRP has been found to be more sensitive and specific than WBC for differentiation between bacterial and viral infection.71-73 In young febrile children,
CRP is superior to WBC in predicting which febrile children have occult
severe bacterial infection74-77 requiring antibiotic therapy. WBC values are
also not consistent enough to be used in monitoring the effect of antibiotic
treatment in bacterial infections.68
CRP versus procalcitonin PCT
Similarly to CRP, PCT is a general marker of bacterial infection.73,75,76,78-83
However, PCT measured at central laboratory is not ideal for routine primary
care84-86 where timely results often are needed to support therapy decisions.
CRP is a good servant
CRP must not be used as the only measure of a patient’s condition. Yet, interpreted in the context of the patient’s symptoms and history, a timely CRP
result is a substantial aid helping the health care practitioner reach the right
diagnosis and correct treatment decision.
13
QuikRead® CRP guides
the use of antibiotics
Diagnostic dilemma
The primary care practitioner has to make
judgement on the cause of patients’ infections more or less every day. A key question is whether the presenting symptoms
are related to a serious bacterial infection
requiring antibiotic treatment or a benign,
self-limiting viral illness.87,88
The clinical signs and symptoms of
patients with bacterial and viral infections frequently overlap and may not
clearly differentiate between these groups of patients.54,87-93 This, together with
pressure from patients, time constraints and the lack of diagnostic tools, may
lead to prescription of unnecessary antibiotics.44,94-96
Although a sample or the patient may be sent to a laboratory for testing,
a test result that is received hours or days later seldom has any effect on the
treatment decision or the course of treatment. Today’s technology allows the
health care practitioner to rapidly perform a diagnostic test and obtain the
result during patient consultation without unnecessary delay.97
QuikRead CRP
QuikRead CRP is an easy-to-use test for quantitative measurement of CRP
on a finger-prick blood sample. The system – consisting of a small portable
instrument and a ready-to-use kit – is especially designed for use in the primary
care setting. When the test is performed near the patient, the result will be
available in a couple of minutes during the patient consultation to support
diagnosis and therapeutic decision-making.
14
In combination with patient history, physical examination and careful
clinical judgement, QuikRead CRP is a valuable tool assisting the health care
practitioner in differentiating between viral and bacterial infections.
A clearly elevated QuikRead CRP result indicates bacterial infection
warranting antibiotic treatment. Conversely, QuikRead CRP can also provide reassurance to both the health care practitioner and the patient in cases
where prescription of antibiotics does not appear justified. By confirming a
likely viral infection, QuikRead CRP can help to reduce unjustified use of
antibiotics98 particularly in connection with respiratory tract infections.99-101
Avoidance of unnecessary antibiotic use will substantially reduce the number
of patients who experience antibiotic-associated adverse events.20 Appropriate
use of antibiotics may also contribute to slowing down or even reversing the
development of antibiotic resistance.102,103
QuikRead CRP provides a reproducible and quantitative result that is as
accurate as that obtained using clinical chemistry analyzers.98,104-107
QuikRead CRP features
• assists in differentiating between viral and bacterial infections
• immediate test result allows the treatment decision to be made during
patient consultation
• small finger-prick blood sample convenient for the patient
• aids in targeting antibiotic therapy to patients most likely to benefit from it
• contributes to reducing unjustified antibiotic prescribing in respiratory tract
infections
• allows monitoring of the efficacy of antibiotic therapy
• simple to operate, easy to read, no special laboratory skills required
• consistent day-to-day results
• quantitative CRP result within the range 5–200 mg/l for QuikRead go and
within the range 8–160 mg/l for QuikRead 101
• comparable to clinical chemistry analysers in accuracy
• in-built calibration
• instrument requires minimum servicing
15
Interpreting the QuikRead® CRP
test result
Optimally, a diagnostic test should have high sensitivity (= the ability of the
test to correctly identify diseased individuals) and high specificity (= the ability
of the test to correctly identify non-diseased individuals).
A cut-off point – a clinical decision threshold – is usually set to discriminate
between diseased and non-diseased individuals. As diagnostic tests, however,
rarely demonstrate 100% sensitivity and specificity, using any single value
as a cut-off will usually cause some overlap, yielding following categories
of test results:
• True positive (TP) = a positive/abnormal test result on a diseased individual
• True negative (TN) = a negative/normal test result on a non-diseased
individual
• False negative (FN) = a negative/normal test result on a diseased individual
• False positive (FP) = a positive/abnormal test result on a non-diseased
individual
Test with low cut-off
Test with high cut-off
• high sensitivity, low specificity
• high specificity, low sensitivity
• likely to identify all diseased
• likely to identify all non-diseased
individuals
• negative/normal result indicates
non-diseased individual: the
disease can be excluded
• will give some false positive results
individuals
• positive/abnormal result indicates
a diseased individual: the disease is
confirmed
• will give some false negative results
The positioning of the cut-off affects both the sensitivity and specificity
of the test (Fig. 3). When the result of a quantitative test such as QuikRead
CRP is interpreted, various cut-off levels may be set depending on what is
considered optimal for each condition – as evidenced by the clinical examples
cited in the following chapter.
16
A low CRP cut-off is generally used to exclude infections of bacterial aetiology. On the other hand, a high CRP cut-off is needed to confirm
bacterial aetiology of an infection. Low and high cut-offs also can be used
simultaneously. Results falling between the cut-offs (“grey area”) require
special consideration.
Fig. 3. Effects of changing the cut-off point of a diagnostic test.108 By permission of Cambridge University Press.
As with any diagnostic test, the QuikRead CRP test result should always
be evaluated in the light of all clinical findings before making the final diagnosis and therapeutic decision.
QuikRead® CRP
in various clinical situations
The following sections discuss the value of QuikRead CRP in various clinical
situations with emphasis on infections commonly encountered in primary care.
17
Serious bacterial infections
Septicaemia, endocarditis, osteomyelitis, septic arthritis, bacterial pneumonia
and meningitis as well as pyelonephritis are usually associated with markedly
elevated CRP concentrations.70,71,73,92,109-119
Measurement of CRP is also useful in the management of feverish conditions without localising signs. Fever is a common symptom in self-limiting,
benign viral illness. However, some febrile patients without apparent source
of infection may have an occult severe bacterial infection that a CRP test
can help confirm.74-76,115
CRP > 10–20 mg/l has
been regarded as
elevated. 66,67,70-
CRP < 50 mg/l may
rule out serious
bacterial infection.73,74
CRP > 100 mg/l suggests severe bacterial
infection.55,60,73,120
77,109,114,117,119
Acute respiratory tract infections
Acute respiratory tract infection (ARTI) is the most frequent reason for
seeking medical attention in primary care121, 122, also accounting for most
antibiotic prescriptions.27,36,37,100,121-126 ARTIs are caused by viruses, bacteria
or a combination of both, and cases of different aetiology often present with
similar symptoms. Identifying patients with a viral infection and patients
suffering from a bacterial infection requiring antibiotics is therefore a daily
challenge in primary health care.
18
Upper respiratory tract infections
Common cold. The common cold is a viral illness in which symptoms like runny nose, sneezing, sore throat and cough are present but not prominent. The
common cold usually resolves spontaneously, although a small
Uncomplicated
viral infections
mostly induce very
modest elevation
of CRP concentration
or none at all.47
proportion may be complicated by bacterial co-infection.127,128
Despite the viral origin, antibiotics are widely prescribed for
patients with the common cold.100,127-129
A normal CRP concentration can help to identify
patients with the common cold for which antibiotics are
not indicated.
Acute sinusitis. Most cases of sinusitis are viral and
uncomplicated but patients are frequently prescribed antibiotics. 90,130-132
Up to 90% of patients with a cold exhibit symptoms of sinusitis in the early
stages of their illness but only a minor part develop bacterial sinusitis.130,133
Bacterial and viral sinusitises are difficult to differentiate based
on clinical symptoms and signs only.54,80,91 Measurement of
CRP assists in diagnosing bacterial sinusitis and in deciding
whether to prescribe antibiotics to a patient with symptoms
of sinusitis.54,100,134
Implementing the CRP test in primary care may lead
CRP > 10-50 mg/l
may suggest
bacterial
sinusitis.55,130,135
to reduction in antibiotic prescribing to patients with
sinusitis.54
Acute pharyngitis. Most cases of acute pharyngitis are caused by viruses. The
most common bacterial cause of acute pharyngitis is Streptococcus pyogenes,
also known as group A ß-haemolytic streptococcus (Strep A). Strep A infection is the only commonly occuring form of sore throat warranting antibiotic
treatment.136-139
Only a minority of sore throats in adults are caused by Strep A, while
children have a higher incidence.136–141 Antibiotics are nonetheless prescribed
to most patients140-142, often to avoid such potentially severe, but nowadays
rare, complications as rheumatic fever and acute glomerulonephritis.139,143
19
A CRP concentration of 35 mg/l
is a useful cut-off point
for differentiating
bacterial and
nonbacterial
pharyngitis.89
As the signs and symptoms of Strep A infection and
those of pharyngitis caused by other micro-organisms
(most commonly viral) often overlap137,138, it is difficult to
make an accurate diagnosis on clinical grounds only.89 To
avoid inappropriate antibiotic treatment of large numbers
of patients with pharyngitis, it is important to verify or
exclude Strep A infection using a diagnostic test136,137,
such as the QuikRead Strep A test.
An immediately available CRP result may also increase the proportion of
sore-throat patients diagnosed correctly and treated adequately.89 Elevated
CRP concentrations have been found in patients with Strep A pharyngitis.89,144-146
Acute otitis media. The incidence of acute otitis media (AOM) is highest
between the ages of 6–12 months147,148, and more than 70% of
children have AOM before their second birthday147.
AOM is generally considered to be a bacterial infection149,150, although also viruses seem to have a role in the
development of AOM.149 Bacterial and viral AOM cannot
CRP > 20 mg/l may
suggest bacterial
otitis media.151
be differentiated on clinical signs and symptoms alone.151
An elevated CRP concentration has been found to
suggest bacterial AOM.151
Lower respiratory tract infections
Acute bronchitis. In acute bronchitis cough is the most frequently observed
symptom, and the illness usually lasts one to three weeks. 152–154 About
70–95% of cases of acute bronchitis are caused by viruses.152,155,156 Bacterial
aetiology has been established in only about 5–10% of patients with acute
bronchitis.152,155
Despite its overwhelmingly viral nature, an estimated 50–90% of doctor’s
office visits for acute bronchitis result in an antibiotic prescription.152,153,157,158
There is little evidence to support the effectiveness of such an approach in
20
CRP < 10-11
mg/l is usually
found in patients with
bronchitis of viral origin61,162,163 and excludes
bacterial CAP.161,163,164
acute bronchitis88,152,156,159, and routine antibiotic treatment
of this illness is therefore not recommended.152,155,159
The evaluation of patients should focus on ruling
out community-acquired pneumonia (CAP) caused by
bacteria.92,152,155,160 Quantitative measurement of CRP
can help to distinguish acute bronchitis from bacterial
CAP.92,154,161 Low CRP concentration along with a history
and clinical findings suggesting a viral infection indicates
that antibiotics are not needed.
Community-acquired pneumonia. A wide variety of viruses, bacteria and
atypical agents can cause community-acquired pneumonia (CAP).165,166
While antibiotics are seldom required for acute lower respiratory tract
infections, which are to a great extent of viral origin, antibiotics are nearly
always indicated for bacterial CAP. A delay in treatment of bacterial CAP
increases the risk of a fatal outcome.167
The prevalence of bacterial CAP is about 5% among patients suspected
of having the infection.160,167
In primary care, CAP is often diagnosed on the basis of symptoms and
physical examination alone, which may be insufficient to identify patients
with bacterial CAP requiring antibiotic treatment. 73,92,93,125,160,161 This is
particularly true in primary care because of the lower incidence and lower
severity of CAP found there.92
Quantitative measurement of CRP in combination with patient history
and clinical findings can contribute to the diagnosis of CAP.55,73,92,125,161,163,167-171
Patients with confirmed bacterial CAP have considerably higher CRP
levels than patients with other acute lower respiratory tract infection.161,163,171
High CRP values may also correlate with disease severity, which may be of
value in deciding about the necessity of inpatient care.163 CRP is also useful
in monitoring the response to antibiotic therapy.161,170
21
CRP < 20 mg/l:
antibiotics are not
indicated in low-risk
patients.92
CRP < 10–11 mg/l:
bacterial CAP can
usually be ruled
out.55,161,163,164
CRP > 100 mg/l:
strong indication
of bacterial
CAP.56,73,161,164,170,171
CRP < 50 mg/l:
antibiotics can often
be withheld.73,125,167
CRP 50–100
mg/l: chest X-ray,
new consultation
within 1-2 days or
prescription of
antibiotics, depending
on the clinical
situation.125
Urinary tract infections
Acute uncomplicated cystitis (lower urinary tract infection) is one of the
most common bacterial infections.172-174 As almost 80–90% of uncomplicated
urinary tract infections in primary care are caused by Escherichia coli172,175,
typical clinical cases are usually managed with minimal evaluation and routine
prescription of an antibiotic.176,177
The most severe form of urinary tract infection is acute pyelonephritis
(upper urinary tract infection), which is associated with significant shortterm morbidity and can cause permanent renal damage.174 If pyelonephritis
is suspected, further investigation is required.
While increased CRP concentration is seldom encountered
in patients with acute uncomplicated cystitis, it is commonly found in patients with acute pyelonephritis.119,178
Quantitative measurement of CRP therefore provides
diagnostic support for differentiating between cystitis
and pyelonephritis. A high CRP concentration in a patient
with urinary tract infection indicates the possibility of
pyelonephritis.119,178-180
22
CRP > 20–40 mg/l
suggests
pyelonephritis.176,178,181,182
QuikRead® CRP in the
routine diagnosis of
acute respiratory tract infection
The decision tree on the following page illustrates potential courses of action
when QuikRead CRP is used to support clinical decision-making in acute
respiratory tract infection.
In this scheme, a CRP concentration of 10 mg/l is used as the clinical cutoff for excluding bacterial infection, although it may lead to overdiagnosis
and unnecessary treatment in some patients without bacterial infection. The
health care practitioner is therefore advised to set an optimal cut-off value
for each condition to achieve the best possible treatment outcome.
An increase in CRP concentration between successive measurements is
usually a sign of the patient’s infection having taken a turn for the worse. A reduction in CRP concentration, on the other hand, is a sign of patient recovery.
This decision tree should be considered only a guide for clinical decisionmaking and should never be relied upon as a substitute for professional
medical judgement.
23
The decision tree
Asthma, allergy, COPD etc
ruled out
ACUTE RESPIRATORY
TRACT INFECTION
Clinical signs,
duration of symptoms
CRP <10 mg/l
Probable viral
cause
Measure CRP
CRP >10 mg/l
Probable bacterial
cause
Patient
recovers
Most likely
bacterial cause
CRP >50 mg/l
Antibiotic prescription
(if clinical picture
requires)
Patient
recovers
Symptomatic
treatment
Patient returns:
symptoms persist /
turn to worse
Patient returns:
symptoms persist /
turn to worse
CRP >10 mg/l
Measure CRP
Measure CRP
CRP <10 mg/l
Additional
investigations /
treatment based on
clinical picture
Patient recovers
24
CRP <10 mg/l
*)
Additional
investigations / possible
change of antibiotics
*) CRP increased compared to previous
measurement / not considerably decreased
The QuikRead® CRP System
QuikRead 101 Instrument
and QuikRead CRP kit with buffer bottle
QuikRead 101 Instrument
and QuikRead CRP kit with prefilled cuvettes
Please also visit
www.quikread.com
QuikRead go Instrument and QuikRead go CRP kit
25
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
26
Dancer SJ. How antibiotics can make us sick: the
less obvious adverse effects of antimicrobial chemotherapy. Lancet Infect Dis 2004;4(10):611-9.
Scott LJ et al. Cefuroxime axetil: an updated review of its use in the management of bacterial
infections. Drugs 2001;61(10):1455-500.
Oliphant CM and Green GM. Quinolones:
a comprehensive review. Am Fam Physician
2002;65:455-64.
Löfmark S et al. Clindamycin-induced enrichment
and long-term persistence of resistant Bacteroides
spp. and resistance genes. J Antimicrob Chemother
2006;58:1160-7.
Jernberg C et al. Long-term ecological impacts of
antibiotic administration on the human intestinal
microbiota. The ISME Journal 2007;1:56-66.
De La Cochetière FM et al. Resilience of the
dominant human fecal microbiota upon shortcourse antibiotic challenge. J Clin Microbiol
2005;43(11):5588-92.
Xu J, Sobel JD. Antibiotic-associated Vulvovaginal
Candidiasis. Curr Infect Dis Rep 2003;5(6):481-7.
Bartosch S et al. Characterization of bacterial
communities in feces from healthy elderly volunteers and hospitalized elderly patients by using
real-time PCR and effects of antibiotic treatment
on the fecal microbiota. Appl Environ Microbiol
2004;70(6):3575-81.
Walk ST, Young VB. Emerging insights into antibiotic-associated diarrhea and Clostridium difficile
infection through the lens of microbial ecology.
Interdiscip Perspect Infect Dis 2008;2008:125081.
Rafii F et al. Effects of treatment with antimicrobial agents on the human colonic microflora. Ther
Clin Risk Manag 2008;4(6):1343-57.
Beaugerie L et al. Antibiotic-associated diarrhea
and Clostridium difficile in the community. Aliment Pharmacol Ther 2003;17:905-912.
Beaugerie L. Antibiotic-associated diarrhea. Best
Pract Res Clin Gastroenterol 2004;18(2):337-52.
De La Cochetière MF et al. Effect of antibiotic
therapy on human fecal microbiota and the relation to the development of Clostridium difficile.
Microb Ecol 2008;56(3):395-402.
Wilcox MH. Clostridium difficile infection and
pseudomembranous colitis. Best Pract Res Clin
Gastroenterol 2003;17(3):475-93.
Pirotta MV et al. ‘’Not thrush again’’. Women’s
experience of post-antibiotic vulvovaginitis. MJA
2003;179:43-6.
Pirotta M et al. Effect of lactobacillus in preventing
post-antibiotic vulvovaginal candidiasis: a randomized controlled trial. BMJ 2004;329(7465):548.
Pirotta MV, Garland SM. Genital Candida species
detected in samples from women in Melbourne,
Australia, before and after treatment with antibiotics. J Clin Microbiol 2006;44(9):3213-7.
Xu J et al. Effect of antibiotics on vulvovaginal
candidiasis: A MetroNet study. J Am Board Fam
Med 2008;21:261-8.
Dethlefsen L et al. the pervasive effects of an antibiotic on the human gut microbiota, as revealed
by deep 16S rRNA sequencing. PLoS Biology
2008;6(11):2383-400.
20. Shehab N et al. Emergency department visits
for antibiotic-associated adverse events. CID
2008;47:735-43.
21. Mehlhorn AJ, Brown DA. Safety concerns
with fluoroquinolones. Ann Pharmacother
2007;41(11):1859-66.
22. Kozyrskyj AL et al. Increased Risk of Childhood
Asthma From Antibiotic Use in Early Life. Chest
2007;131(6):1753-9.
23. Marra F et al. Does antibiotic exposure during infancy lead to development of asthma?:
a systematic review and metaanalysis. Chest.
2006;129(3):610-8.
24. Marra F et al. Antibiotic use in children is associated with increased risk of asthma. Pediatrics.
2009;123(3):1003-10.
25. World Health Organization (WHO). WHO Global Strategy for Containment of Antimicrobial
Resistance. Available at http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf.
Accessed on 26 July 2007.
26. Centers for Disease Control and Prevention
(CDC). Antibiotic/Antimicrobial Resistance. Available at www.cdc.gov/drugresistance. Accessed on
26 July 2007.
27. Goossens H et al. Outpatient antibiotic
use in Europe and association with resistance: a cross-national database study. Lancet
2005;365(9459):579-87.
28. Harbarth S, Samore MH. Antimicrobial Resistance Determinants and Future Control. Emerg Inf
Dis 2005;11(6):794-801.
29. Bronzwaer SLAM et al. A European Study on
the Relationship between Antimicrobial Use
and Antimicrobial Resistance. Emerg Infect Dis
2002;8(3):278-82.
30. Albrich WC et al. Antibiotic Selection Pressure
and Resistance in Streptococcus pneumoniae
and Streptococcus pyogenes. Emerg Infect Dis
2004;10(3):514-7.
31. Infectious Diseases Society of America (ISDA).
Bad Bugs, No Drugs. As Antibiotic Discovery
Stagnates… A Public Health Crisis Brews. 2004.
Available at http://www.idsociety.org/pa/IDSA_Paper4_final_web.pdf. Accessed on 26 July 2007.
32. Norrby SR et al. Lack of development of new
antimicrobial drugs: a potential serious threat to
public health. Lancet Infect Dis 2005;5(2):115-9.
33. Hooton TM, Levy SB. Antimicrobial Resistance: A
Plan of Action for Community Practice. Am Fam
Physician 2001;63(6):1087-96.
34. European Commission. Antibiotic resistance. A
growing threat. Prudent use of antibiotics is vital.
Available at http://europa.eu.int/comm/research/
leafl ets/antibiotics/page_28_en.html. Accessed on
26 July 2007.
35. Kuyvenhoven MM et al. Outpatient antibiotic prescriptions from 1992 to 2001 in the Netherlands. J
Antimicrob Chemother 2003;52(4):675-8.
36. Wise R et al. Antimicrobial resistance is a major
threat to public health. BMJ 1998;317(7159):60910.
37. Huovinen P, Cars OC. Control of antimicrobial resistance: time for action. The essentials of control are already well known. BMJ
1998;317(7159):613-4.
38. Steinman MA. Predictors of Broad-Spectrum
Antibiotic Prescribing for Acute Respiratory
Tract Infections in Adult Primary Care. JAMA
2003;289(6):719-25.
39. Gill JM et al. Use of Antibiotics for Adult Upper
Respiratory Infections in Outpatient Settings: A
National Ambulatory Network Study. Fam Med
2006:38(5):349-54.
40. Spellberg B et al. Trends in Antimicrobial Drug
Development: Implications for the Future. Clin
Infect Dis 2004;38(9):1279-86.
41. Tufts Center for the Study of Drug Development.
Backgrounder: How New Drugs Move through
the Development and Approval Process. News
item 11/1/2001. Available at http://csdd.tufts.edu/
NewsEvents/RecentNews.asp?newsid=4. Accessed
on 26 July 2007.
42. Cars O et al. Variation in antibiotic use in the
European Union. Lancet 2001;357(9271):1851-3.
43. APUA – Alliance for the Prudent Use of Antibiotics. What can be done about antibiotic resistance? Available at http://www.tufts.edu/med/
apua/Q&A/Q&A_action.html. Accessed on 26
July 2007.
44. Nordberg P et al. Consumers and Providers – could
they make better use of antibiotics? The Global
Threat of Antibiotic Resistance: Exploring Roads
towards Concerted Action. A multidisciplinary
meeting at the Dag Hammarskjöld Foundation,
Uppsala, Sweden, 5-7 May 2004. Background material. Available at http://soapimg.icecube.snowfall.se/stopresistance/Consumers_and_providers.
pdf. Accessed on 26 July 2007.
45. Harbarth S et al. Outpatient Antibiotic Use and
Prevalence of Antibiotic-Resistant Pneumococci in
France and Germany: A Sociocultural Perspective.
Emerg Infect Dis 2002;8(12):1460-7.
46. Coenen S et al. European Surveillance of Antimicrobial Consumption: Outpatient parenteral antibiotic treatment in Europe. Available at http://www.
esac.ua.ac.be/main.aspx?c=*ESAC2&n=50034.
Accessed on 9 September 2010.
47. Pepys MB. The acute phase response and C-reactive protein. In: Warrell DA, Cox TM, Firth JD,
Benz EJ, eds. Oxford Textbook of Medicine, 4th
ed. Oxford University Press, 2003 Vol 2, p. 150-6.
48. Tietz NW. Clinical Guide to Laboratory Tests, 3rd
Edition. WB Saunders Company.
49. Myers GL et al. CDC/AHA Workshop on Markers of Inflammation and Cardiovascular Disease:
Application to Clinical and Public Health Practice:
Report From the Laboratory Science Discussion
Group. Circulation 2004;110(25):e545-9.
50. Macy EM et al. Variability in the measurement of
C-reactive protein in healthy subjects: implications
for reference intervals and epidemiological applications. Clin Chem 1997;43(1):52-8.
51. Weitkamp J-H, Achner JL. Diagnostic Use of CReactive Protein (CRP) in Assessment of Neonatal
Sepsis. NeoReviews 2005;6(11):e508-15.
52. Thompson D et al. The physiological structure of
human C-reactive protein and its complex with
phosphocholine. Structure 1999;7(2):169-77.
53. Du Clos TW, Mold C. The role of C-reactive protein in the resolution of bacterial infection. Curr
Opin Infect Dis 2001;14(3):289-93.
54. Bjerrum L et al. C-reactive protein measurement in general practice may lead to lower antibiotic prescribing for sinusitis. Br J Gen Pract
2004;54(506):659-62.
55. Melbye H, Stocks N. Point of care testing for Creactive protein. A new path for Australian GPs?
Aust Fam Physician 2006;35(7):513-6.
56. Pepys MB. C-reactive protein fifty years on. Lancet
1981;1:653-7.
57. Black S et al. C-reactive Protein. J Biol Chem
2004;279(47):48487-90.
58. Gabay G, Kushner I. Acute-Phase Proteins and
Other Systemic Responses to Inflammation. N Eng
J Med 1999:340(6):448-454.
59. Hansson L-O; Lindqvist L. C-reactive protein: its
role in the diagnosis and follow-up of infectious
diseases. Curr Opin Inf Dis 1997;10:196-201.
60. Morley JJ, Kushner I. Serum C-reactive protein
levels in disease. Ann N Y Acad Sci 1982;389:40618.
61. Melbye H et al. The course of C-reactive protein
response in untreated upper respiratory tract infection. Br J Gen Pract 2004;54(506):653-8.
62. Appenzeller C et al. Serum C-reactive protein in
children with adenovirus infection. Swiss Med
Wkly 2002;132(25-26):345-50.
63. Mäkelä MJ et al. Viruses and Bacteria in the
Etiology of the Common Cold. J Clin Micro
1998;36(2):539-42.
64. Heikkinen T, Järvinen A. The common cold. Lancet 2003;361(9351):51-9.
65. Gwaltney JM Jr. The common cold. In: Mandell
GL et al (eds.). Principles and practice of infectious diseases, 5th edn. Philadelphia: Churchill
Livingstone, 2000;651-65.
66. Ehl S et al. C-Reactive Protein Is a Useful Marker
for Guiding Duration of Antibiotic Therapy in
Suspected Neonatal Bacterial Infection. Pediatrics
1997;99(2):216-21.
67. Philip AGS, Mills PC. Use of C-Reactive Protein in
Minimizing Antibiotic Exposure: Experience With
Infants Initially Admitted to a Well-Baby Nursery.
Pediatrics 2000;106(1):E4.
68. Roine I et al. Serial serum C-reactive protein
to monitor recovery from acute hematogenous
osteomyelitis in children. Pediatr Infect Dis J
1995;14(1):40-4.
69. Bridgen ML. Clinical Utility of the Erythrocyte Sedimentation Rate. Am Fam Physician
1999;60(5):1443-50.
70. Peltola H et al. Simplified Treatment of Acute Staphylococcal Osteomyelitis of Childhood. Pediatrics 1997;99(6):846-50.
71. Sormunen P, et al. C-reactive protein is useful in
distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children. J Pediatr
1999;134(6):725-9.
72. Hsiao AL, Baker MD. Fever in the new millennium: a review of recent studies of markers of
serious bacterial infection in febrile children. Curr
Opin Pediatr 2005;17(1):56-61.
73. Stolz D et al. Diagnostic value of signs, symptoms and laboratory values in lower respiratory
tract infection. Swiss Med Wkly 2006;136:(2728):434-40.
74. Pulliam PN et al. C-Reactive Protein in Febrile
Children 1 to 36 Months of Age With Clinically
Undetectable Serious Bacterial Infection. Pediatrics
2001;108(6):1275-9.
27
75. Galetto-Lacour A et al. Procalcitonin, IL-6, IL-8,
IL-1 receptor antagonist and C-reactive protein
as indicators of serious bacterial infections in
children with fever without localising signs. Eur
J Pediatr 2001;160(2):96-100.
76. Galetto-Lacour A et al. Bedside Procalcitonin and
C-Reactive Protein Test in Children With Fever
Without Localizing Signs of Infection Seen in a
Referral Center. Pediatrics 2003;112(5):1054-60.
77. Pratt A, Attia MW. Duration of fever and markers of serious bacterial infection in young febrile
children. Pediatr Int 2007;49(1):31-5.
78. Enguix A et al. Comparison of procalcitonin
with C-reactive protein and serum amyloid for
the early diagnosis of bacterial sepsis in critically
ill neonates and children. Intensive Care Med
2001;27(1):211-5.
79. Chan Y-L et al. Procalcitonin as a marker of bacterial infection in the emergency department: an
observational study. Critical Care 2004;8(1):R12R20.
80. Lopez Sastre JB et al. Procalcitonin is not sufficiently reliable to be the sole marker of neonatal sepsis of nosocomial origin. BMC Pediatrics
2006;6(16).
81. Tang BMP et al. Accuracy of procalcitonin for
sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis
2007;7(3):210-17.
82. Thayyil S et al. Is procalcitonin useful in early diagnosis of serious bacterial infections in children?
Acta Paediatr 2005;94(2):155-8.
83. Andreola B et al. Procalcitonin and C-reactive
protein as diagnostic markers of severe bacterial infections in febrile infants and children in
the emergency department. Pediatr Infect Dis J
2007;26(8):672-7.
84. Briel M et al. Procalcitonin-guided antibiotic use
versus a standard approach for acute respiratory
tract infections in primary care: study protocol for
a randomised controlled trial and baseline characteristics of participating general practitioners
[ISRCTN73182671]. BMC Fam Pract 2005;6:34.
85. Loens K et al. Is there a role for CRP or PCT
as inflammatory parameters in the management
of outpatients with community-acquired lower
respiratory tract infections? Clin Microbiol Infect
2010;16(Suppl.2):S381. Abstract.
86. Holm A. Procalcitonin versus C-reactive protein
for predicting pneumonia in adults with lower
respiratory tract infection in primary care. Br J
Gen Pract 2007;57(540):555–560.
87. Wilson EJ et al. Changing GP’s antibiotic prescribing: a randomised controlled trial. Commun Dis
Intell 2003;27(Suppl):S32-S38.
88. Fahey T et al. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2004, Issue
4. Art. No.: CD000245. DOI:10.1002/14651858.
CD000245.pub2.
89. Gulich MS et al. Improving diagnostic accuracy
of bacterial pharyngitis by near patient measurement of C-reactive protein (CRP). Br J Gen Pract
1999;49:119-21.
90. Hickner JM et al. Principles of Appropriate Antibiotic Use for Acute Rhinosinusitis in Adults: Background. Ann Intern Med 2001;134(6):498-505.
91. Desrosiers M et al. Acute Bacterial Sinusitis in
Adults: Management in the Primary Care Setting.
J Otolaryngol 2002;31(S2):2S2-14.
28
92. Hopstaken RM, et al. Contributions of symptoms, signs, erythrocyte sedimentation rate, and
C-reactive protein to a diagnosis of pneumonia
in acute lower respiratory tract infection. B J Gen
Pract 2003;53(490):358-64.
93. Hopstaken RM et al. Do clinical findings in lower
respiratory tract infection help general practitioners prescribe antibiotics appropriately? An observational cohort study in general practice. Fam
Pract 2005;23(2):180-7.
94. File TM, Hadley JA. Rational Use of Antibiotics
to Treat Respiratory Tract Infections. Am J Manag
Care 2002;8(8):713-27.
95. Arnold SR, Strauss SE. Interventions to improve
antibiotic prescribing practices in ambulatory care.
The Cochrane Database of Systematic Reviews
2005, Issue 4. Art. No.: CD003539.pub2. DOI:
10.1002/14651858.CD003539.pub2.
96. Pétursson P. Why Non-Pharmacological Prescribing of Antibiotics? – A Phenomenological Investigation into the Rationale behind it from the
GP’s perspective. Master of Public Health Essay
(Nordic School of Public Health). MPH 2005:6.
97. Price CP, Hicks JM. eds. Point-of-Care testing.
Washington: AACC Press 1999.
98. Papaevangelou V et al. Evaluation of a quick test for
C-reactive protein in a pediatric emergency department. Scan J Clin Lab Invest 2006;66(8):717-22.
99. Mészner Z, Kovács T. C-reactive protein quick
test, as a diagnostic aid in primary paediatric care
in Hungary. A prospective study. Poster presented
at the 24th Congress European Society for Paediatric Infectious Diseases, Basel, Switzerland
3-5.5.2006.
100.Bjerrum L et al. Effect of intervention promoting
a reduction in antibiotic prescribing by improvement of diagnostic procedures: a prospective, before and after study in general practice. Eur J Clin
Pharmacol 2006;62(11):913-8.
101.Cals J et al. Point-of-care C-reactive protein testing
and antibiotic prescribing for respiratory tract infections: A randomized controlled trial. Ann Fam
Med 2010;8:124-133.
102.Seppälä H et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland.
N Engl J Med 1997:337(7):441-6.
103.Stephenson J. Icelandic researchers are showing
the way to bring down rates of antibiotic-resistant
bacteria. JAMA 1996;275(3):175.
104.Ylianttila M, Raussi J. QuikRead go®, a new
point-of-care test system for quantitative determination of C-Reactive Protein in Blood samples.
Poster presented at Laboratory Medicine 2010/
XXXII Nordic Congress in Clinical Chemistry,
Oslo, Norway, 1 – 4 June 2010.
105.Paloheimo L et al. A Fast B.CRP Assay for NearPatient Testing (NPT) or Point-of-Care Testing
(POCT). Poster presented at Laboratory Medicine
2000/XXVII Nordic Congress of Clinical Chemistry, Bergen, Norway, 4-8 June 2000.
106.Seamark DA et al. Field-testing and validation in a primary care setting of a point-of-care
test for C-reactive protein. Ann Clin Biochem
2003;40(Pt2):178-80.
107.Esposito S, et al. Evaluation of a rapid bedside test
for the quantitative determination of C-reactive
protein. Clin Chem Lab Med 2005;43(4):438-40.
108.Mayer D. Essential Evidence-Based Medicine.
Cambridge University Press 2004
109.Hansson LO, Lindquist L. C-reactive protein: its
role in the diagnosis and follow-up of infectious
diseases. Curr Opin Infect Dis 1997;10(3):196201.
110.Peltola H, Jaakkola M. Serious Bacterial Infections. C-reactive Protein as a Serial Index of Severity. Clin Pediatr 1988;27(11):532-7.
111.Hogevik H et al. C-Reactive Protein is More Sensitive than Erythrocyte Sedimentation Rate for
Diagnosis of Infective Endocarditis. Infection
1997;25(2):14/82-17/85
112.Heiro M et al. Utility of serum C-reactive protein
in assessing the outcome of infective endocarditis.
Eur Hearth J 2005;26(18):1873-81.
113.Lew DP, Waldvogel FA. Osteomyelitis. Lancet
2004;364(9431):369-79.
114.Unkila-Kallio L et al. The usefulness of C-reactive
protein levels in the identification of concurrent
septic arthritis in children who have acute hematogenous osteomyelitis. A comparison with the
usefulness of the erythrocyte sedimentation rate
and the white blood-cell count. J Bone Joint Surg
Am 1994;76(6):848-53.
115.Maheshwari N. How useful is C-reactive protein
in detecting occult bacterial infection in young
children with fever without apparent focus? Arch
Dis Child 2006;91(6):533-5.
116.Levine MJ et al. Assessment of the Test Characteristics of C-reactive Protein for Septic Arthritis
in Children. J Pediatr Orthop 2003;23(3):373-7.
117.Tatara R, Imai H. Serum C-reactive protein in
the differential diagnosis of childhood meningitis.
Pediatr Int 2000;42(5):541-6.
118.Huntley JS, Kelly MB. C-reactive protein: a valuable acute investigation. A case of pneumococcal
meningitis presenting as ankle pain. Emerg Med J
2005;22(8):602-3.
119.Jodal U, et al. Level diagnosis of symptomatic urinary tract infections in childhood. Acta Paediatr
Scand 1975;64(2):201-8.
120.Seaton RA, Nathwani D. Rationale for sepsis management in immunocompetent adults. Proc R Coll
Physician Edinb 2000;30.
121.Grimsmo A et al. Patients, diagnoses and processes
in general practice in the Nordic countries. An
attempt to make data from computerised medical
records available for comparable statistics. Scand
J Prim Health Care 2001;19(2):76-82.
122.Linder JA et al. Association between antibiotic
prescribing and visit duration in adults with
upper respiratory tract infections. Clin Ther
2003;25(9):2419-30.
123.Gonzales R et al. Excessive Antibiotic Use for
Acute Respiratory Infections in the United States.
Clin Infect Dis 2001;33(6):757-62.
124.Raherison C et al. Management of lower respiratory tract infections by French general practitioners:
the AIR II study. Eur Respir J 2002;19(2):314-9.
125.Mölstad S. Reduction in antibiotic prescribing for
respiratory tract infections is needed! Scand J Prim
Health Care 2003;21(4):196-8.
126.Stocks NP et al. Acute bronchitis in Australian
general practice. A prescription too far? Aust Fam
Physician 2004;33(1-2):91-3.
127.Gonzales R et al. Principles of Appropriate Antibiotic Use for Treatment of Nonspecific Upper Respiratory Tract Infections in Adults: Background.
Ann Intern Med 2001;134(6):490-4.
128.Heikkinen T, Järvinen A. The common cold. Lancet 2003;361(9351):51-9.
129.Arroll B, Kenealy T. Antibiotics for the common
cold and acute purulent rhinitis. The Cochrane
Database of Systematic Reviews 2005, Issue 3, Art.
No.: CD000247.pub2. DOI:10.1002/14651858.
CD000247.pub2.
130.Lindbaek M. Acute Sinusitis. Guide to Selection of
Antibacterial Therapy. Drugs 2004;64(8):805-19.
131.Varonen H et al. Management of acute maxillary sinusitis in Finnish primary care. Scan J Prim
Health Care 2004;22(2)122-7.
132.Dosh SA et al. Predictors of antibiotic prescribing
for non-specific upper respiratory infections, acute
bronchitis, and acute sinusitis. An UPRNet study.
Uppre Peninsula Research Network. J Fam Pract
2000;49(5):407-14.
133.Gwaltney Jr JM. Acute Community-Acquired
Bacterial Sinusitis: The Value of Antimicrobial
Treatment and the Natural History. Clin Infect
Dis 2004;38(2):227-33.
134.Hansen JG et al. Randomised, double blind,
placebo controlled trial of penicillin V in the
treatment of acute maxillary sinusitis in adults
in general practice. Scand J Prim Health Care
2000;18(1):44-7.
135.Lindbæk M, Hjortdahl P. The clinical diagnosis
of acute purulent sinusitis in general practice –
a review. Br J Gen Pract 2002;52(479):491-495.
136.Bisno AL. Acute pharyngitis. N Engl J Med
2001;344(3):205-11.
137.Bisno AL et al. Practice Guidelines for the Diagnosis and Management of Group A Streptococcal
Pharyngitis. Clin Infect Dis 2002;35(2);113-25.
138.Cooper RJ et al. Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background. Ann Intern Med 2001;134(6):509-17.
139.Snow V et al. Principles of Appropriate Antibiotic
Use for Acute Pharyngitis in Adults. Ann Intern
Med 2001;134(6):506-8.
140.Linder JA, Stafford RS. Antibiotic treatment of
Adults With Sore Throat by Community Primary
Care Physicians: A National Survey, 1989-1999.
JAMA 2001;286(16):1181-6.
141.Linder JA et al. Antibiotic Treatment of Children
With Sore Throat. JAMA 2005;294(18):2315-22.
142.Del Mar CB et al. Antibiotics for sore throat.
The Cochrane Database of Systematic Reviews
2006, Issue 4, Art. No. CD000023.pub2. DOI:
10.1002/14651858.CD000023.pub3.
143.Olivier C. Rheumatic fever – is it still a problem?
J Antimicrob Chemother 2000;45(Suppl):13-21.
144.Hjortdahl P, Melbye H. Does near-to-patient testing contribute to the diagnosis of streptococcal
pharyngitis in adults? Scand J Prim Health Care
1994;12(2)70-6.
145.Melbye H et al. Daily reduction in C-reactive protein values, symptoms, signs and temperature in
group-A streptococcal pharyngitis treated with antibiotics. Scand J Clin Lab Invest 2002;62(7):521-5.
146.Ayranci U et al. Antibiotic prescribing patterns for
sore throat infections in a university-based primary care clinic. Ann Saudi Med 2005;25(1):22-8.
29
147.Alho O-P et al. The occurrence of acute otitis media in infants: A life-table analysis. Int J Pediatr
Otorhinolaryngol 1991;21(1):7-14.
148.Teele DW et al. Epidemiology of Otitis Media
During the First Seven Years of Life in Children
in Greater Boston: A Prospective, Cohort Study. J
Infect Dis 1989;160(1):83-94.
149.Heikkinen T, Chonmaitree T. Importance of Respiratory Viruses in Acute Otitis Media. Clin Microbiol Rev 2003;16(2):230-41.
150.Palmu AAI et al. Association of Clinical Signs and
Symptoms with Bacterial Findings in Acute Otitis
Media. Clin Infect Dis 2004:38(2):234-42.
151.Tejani NR et al. Use of C-Reactive Protein in Differentiation Between Acute Bacterial and Viral
Otitis Media. Pediatrics 1995;95(5):664-9.
152.Gonzales R, Sande MA. Uncomplicated Acute
Bronchitis. Ann Intern Med 2000;133(12):981-91.
153.Holmes WF et al. Symptoms, signs, and prescribing for acute lower respiratory tract illness. Br J
Gen Pract 2001;51(464);177-81.
154.Aagaard E, Gonzales R. Management of acute
bronchitis in healthy adults. Infect Dis Clin North
Am 2004;18(4):919-37.
155.Gonzales R et al. Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated
Acute Bronchitis: Background. Ann Intern Med
2001;134(6):521-9.
156.Hueston WJ, Mainous AG. Acute Bronchitis. Am
Fam Physician 1998;57(6):1270-6, 1281-2.
157.European Commission. EU acts to combat resistance to antibiotics. Press Release IP/06/323 of 17
March 2006. Available at http://www.europa.
eu.int/rapid/pressReleasesAction.do?reference=IP
/06/323&format=HTML&aged=0&language=E
N&guiLanguage=en. Accessed on 26 July 2007.
158.Macfarlane JT et al. Contemporary use of antibiotics in 1089 adults presenting with acute lower
respiratory tract illness in general practice in the
UK: implications for developing management
guidelines. Respir Med 1997;91(7):427-34.
159.Gwaltney Jr JM. Acute Bronchitis. In: Mandell GL,
Bennett JE, Dolin R, eds. Principles and practice
of infectious diseases. 4th ed. New York: Churchill
Livingstone, 1995:606-8.
160.Metlay JP, Fine MJ. Testing Strategies in the
Initial Management of Patients with Community-Acquired Pneumonia. Ann Intern Med
2003;138(2):109-18.
161.Smith RP, Lipworth BJ. C-reactive protein in
simple community acquired pneumonia. Chest
1995;107(4):1028-31.
162.Jonsson JS et al. Acute bronchitis in adults. How
close can we come to its aetiology in general practice? Scand J Prim Health Care 1997;15(3):156-60.
163.Almirall J et al. Contribution of C-Reactive Protein to the Diagnosis and Assessment of Severity of Community-Acquired Pneumonia. Chest
2004;125(4):1335-42.
164.Melbye H. Community pneumonia: More help is
needed to diagnose and assess severity. Br J Gen
Pract 2002;52(484):886-8.
165.Bjerre LM et al. Antibiotics for community acquired pneumonia in adult outpatients. The
Cochrane Database of Systematic Reviews
2004, Issue 2. Art. No.: CD002109.pub2.
DOI:10.1002/14651858.CD002109.pub2.
30
166.Donowitz GR, Mandell GL. Acute pneumonia. In:
Mandell GL, Bennett JE, Dolin R, eds. Principles
and practice of infectious diseases. 4th ed. New
York: Churchill Livingstone, 1995:619-37.
167.Örtqvist Å. Treatment of community-acquired
lower respiratory tract infections in adults. Eur
Respir J Suppl 2002;(36):40s-53s.
168.Macfarlane J. Lower Respiratory Tract Infection
and Pneumonia in the Community. Semin Respir
Infect 1999;14(2):151-162.
169.Luna CM. C-Reactive Protein in Pneumonia. Let
Me Try Again. Chest 2004;125(4):1192-5.
170.Castro-Guardiola A et al. Differential diagnosis
between community acquired pneumonia and
non-pneumonia diseases of the chest in the emergency ward. Eur J Int Med 2000;11(6):334-9.
171.Flanders SA et al. Performance of a Bedside CReactive Protein Test in the Diagnosis of Community-Acquired Pneumonia in Adults with Acute
Cough. Am J Med 2004;116(8):529-35.
172.Hooton TM et al. Acute Uncomplicated Cystitis
in an Era of Increasing Antibiotic Resistance: A
Proposed Approach to Empirical Therapy. Clin
Infect Dis 2004;39(1):75-80.
173.Nicolle LE. Epidemiology of Urinary Tract
Infections. Clin Microbiology Newsletter
2002;24(18):135-40.
174.Bloomfield P et al. Antibiotics for acute pyelonephritis in children. The Cochrane Database
of Systematic Reviews 2005, Issue 1. Art. No.:
CD003772.pub2. DOI: 10.1002/14651858.
CD003772.pub2.
175.Milo G et al. Duration of antibacterial treatment for uncomplicated urinary tract infection
in women. The Cochrane Database of Systematic
Reviews 2005, Issue 2. Art. No.: CD004682.pub2.
DOI:10.1002/14651858.CD004682.pub2.
176.Ikäheimo R et al. Virtsatieinfektiot (Urinary tract
infections, Finnish EMB guidelines, in Finnish).
Duodecim 2000;116:782-796.
177.Gupta K et al. Increasing Antimicrobial Resistance
and the Management of Uncomplicated Community-Acquired Urinary Tract Infections. Ann Intern
Med 2001;135(1):41-50.
178.Sandberg T et al. Host response in Women with
Symptomatic Urinary Tract Infection. Scand J Infect Dis 1989;21(1):67-73.
179.Yen C-W, Chen D-H. Urinary Tract Infection in Children. J Microbiol Immunol Infect
1999;32:199-205.
180.Bjerklund Johansen TE. Diagnosis and imaging in urinary tract infections. Curr Opin Urol
2002;12(1):39-43.
181.Meyrier A. Urinary Tract Infection. In Atlas of
Diseases of the Kidney, Vol. 2. Blackwell Science
1999. Available at www.kidneyatlas.org. Accessed
on 26 February 2007.
182.Naber KG et al. Guidelines on The Management
of Urinary and Male Genital Tract Infections. European Association of Urology 2006.
806-06GB, 7/2012
31
Orion Diagnostica Oy
Koivu-Mankkaan tie 6 B, P.O. Box 83, FI-02101 Espoo, Finland
Tel. +358 10 4261, Fax +358 10 426 2794
www.oriondiagnostica.com, www.quikread.com