Using the CRP Test in Children Under 12 Years With Respiratory Symptoms in Kyrgyz Republic

INTRODUCTION AND RATIONALE

Respiratory tract infections are the most common cause of contact to the health system and are the main reason for antibiotic overuse at the primary care level globally. At the same time, acute lower respiratory infections (ALRI) are the most common cause of death among children under 5 globally, costing the lives of almost 1 million children annually. Unfortunately, there is substantial overlap in the presentation of different causes of acute lower respiratory illness in young children, including bacterial pneumonia, viral infections and wheezing and with increasing coverage of pneumococcal and Haemophilus influenza type b vaccination, only a smaller proportion of these need antibiotics. At the same time, globally, most children are diagnosed and treated at a primary care clinic, primarily by mid-level providers with only limited access to diagnostic equipment. To assist healthcare providers in diagnosing under these conditions, various algorithms have been used, e.g. WHO's Integrated Management of Childhood Illness, which bases diagnosis of respiratory diseases in children mainly on presence of cough and elevated respiratory rate. This approach has been shown to severely over-diagnose pneumonia and thus result in unnecessary prescription of antibiotics. Therefore, new approaches to diagnosing and treating respiratory infections in children are urgently needed.

Concurrently, antimicrobial resistance is now what WHO calls a global health emergency and warns that 'A post-antibiotic era - in which common infections and minor injuries can kill - far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century. Unnecessary prescription of antibiotics is extensive globally and most healthcare providers are aware of the global threat of antimicrobial resistance but express the need for support for prescribing differently, such as knowledge of local resistance patterns of pathogens and better diagnostics to support a decision not to treat with an antibiotic.

C-reactive protein (CRP) is an acute phase reactant produced by the liver which can be used as a marker of serious infection. Randomised trials of using CRP point of care test (POCT) to guide antibiotic prescription for respiratory tract infections has been successful in lowering unnecessary antibiotic prescriptions in adults in high income countries but left a small concern for safety in the form of possibly slightly increased risk of hospitalisation in the CRP group. Trials of CRP POCT in children have been performed in Tanzania as part of an intervention package with a strict prescription limit of > 80 mg/L CRP with a reduction in antibiotic prescriptions from 40% to 2%. In South-East Asia with a small but statistically significant effect (5% reduction) when used as either above or below a certain threshold (40 mg/L) in Thailand and Myanmar. In a sub-group analysis from a trial in Vietnam with both children and adults where the numeric value of CRP was used after a short training in CRP interpretation along with clinical evaluation resulted in a 20% reduction from 64% to 44%. A cross-cutting qualitative study of the above-mentioned studies in Thailand, Myanmar, and Vietnam showed that lack of non-antibiotic alternatives to prescribe led to lower adherence to the CRP POCT result.

As the intervention of supplying CRP POCT to healthcare providers is more a behavioural than biomedical, previous trials have recommended that further trials are done in different contexts and that qualitative studies of reasons for success or failure.