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This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered., This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered.

The world faces the threat of increasing antimicrobial resistance, and there is growing consensus that swift action must be taken to improve the rational use of antibiotics and increase the stewardship of antibiotics to safeguard this key resource in modern healthcare. This paper provides the perspective of an international group of experts on the role of C-reactive protein point-of-care testing (CRP POCT) and other complementary strategies to improve antibiotic stewardship in primary care, with regards to the diagnosis and treatment of adult patients presenting symptoms of lower respiratory tract infections (LRTIs). It provides guidance regarding the clinical assessment of symptoms in combination with C-reactive protein (CRP) results, at the point of care, to support the management decision, and discusses enhanced patient communication and delayed prescribing as complementary strategies to decrease the inappropriate use of antibiotics. Recommendation: CRP POCT should be promoted to improve the identification of adults presenting with symptoms of LRTIs in primary care who might gain additional benefit from antibiotic treatment. Appropriateness of antibiotic use can be maximized when CRP POCT is used together with complementary strategies such as enhanced communication skills training and delayed prescribing in addition to routine safety netting.

Tackling antibiotic resistance represents one of the major challenges in modern medicine, and limiting antibiotics’ overuse represents the first step in this fight. Most antibiotics are prescribed in primary care settings, and lower respiratory tract infections (LRTIs) are one of the most common indications for their prescription. An expert panel conducted an extensive report on C-reactive protein point-of-care (CRP POC) testing in the evaluation of LRTIs and its usefulness to limit antibiotic prescriptions. The expert panel stated that CRP POC testing is a potentially useful tool to limit antibiotic prescriptions for LRTI in a community setting. CRP POC must be used in conjunction with other strategies such as improved communication skills and the use of other molecular POC testing. Potential barriers to the adoption of CRP POC testing are financial and logistical issues. Moreover, the efficacy in limiting antibiotic prescriptions could be hampered by the fact that, in some countries, patients may gain access to antibiotics even without a prescription. Through the realization of a better reimbursement structure, the inclusion in standardized procedures in local guidelines, and better patient education, CRP point-of-care testing can represent a cornerstone in the fight against antimicrobial resistance.

David Gillespie,1,2 Nick Francis,3 Haroon Ahmed,4 Kerenza Hood,2 Carl Llor,5 Patrick White,6 Emma Thomas-Jones,2 Helen Stanton,2 Bernadette Sewell,7 Rhiannon Phillips,8 Gurudutt Naik,4 Hasse Melbye,9 Rachel Lowe,2 Nigel Kirby,2 Ann Cochrane,10 Janine Bates,2 Mohammed Fasihul Alam,11 Christopher Butler1 1Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK; 2Centre for Trials Research, School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Cardiff, Wales, UK; 3Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK; 4Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK; 5University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain; 6School of Population Health and Environmental Sciences, Kings College London, London, England, UK; 7Swansea Centre for Health Economics, Swansea University, Swansea, Wales, UK; 8Cardiff School of Sport & Health Science, Cardiff Metropolitan University, Cardiff, Wales, UK; 9General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 10York Trials Unit, Department of Health Sciences, University of York, York, England, UK; 11Department of Public Health, College of Health Sciences, QU-Health, Qatar University, Doha, QatarCorrespondence: David Gillespie, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, England, OX2 6GG, UK, Email david.gillespie@phc.ox.ac.ukBackground: It has been demonstrated that antibiotic prescribing for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) can be safely reduced in primary care when general practitioners have access to C-reactive protein (CRP) rapid testing.Aim: To investigate the factors associated with post-consultation COPD health status in patients

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.

Sarah Cook,1– 3 Anne Elise Eggen,1 Laila A Hopstock,1 Sofia Malyutina,4,5 Marina Shapkina,4 Alexander V Kudryavtsev,1,6 Hasse Melbye,1,* Jennifer K Quint3,* 1Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway; 2Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; 3National Heart and Lung Institute, Imperial College London, London, UK; 4Research Institute of Internal and Preventive Medicine, Branch of Institute of Cytology and Genetics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russian Federation; 5Novosibirsk State Medical University, Russian Ministry of Health, Novosibirsk, Russian Federation; 6Northern State Medical University, Arkhangelsk, Russian Federation*These authors contributed equally to this workCorrespondence: Sarah Cook Email sarah.cook@lshtm.ac.ukBackground: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Despite a high prevalence of smoking and respiratory symptoms, two recent population-based studies in Russia found a relatively low prevalence of obstructive lung function. Here, we investigated the prevalence of both obstructive lung disease and respiratory symptoms in a population-based study conducted in two Russian cities and compared the findings with a similar study from Norway conducted in the same time period.Methods: The study population was a sub-sample of participants aged 40– 69 years participating in the Know Your Heart (KYH) study in Russia in 2015– 18 (n=1883) and in the 7th survey of the Tromsø Study (n=5271) carried out in Norway in 2015– 16 (Tromsø 7) who participated in spirometry examinations. The main outcome was obstructive lung function (FEV1/FVC ratio< lower limit of normal on pre-bronchodilator spirometry examination) with and without respiratory symptoms (chronic cough and breathl

Nick A Francis,1 David Gillespie,2 Mandy Wootton,3 Patrick White,4 Janine Bates,2 Jennifer Richards,3 Hasse Melbye,5 Kerenza Hood,2 Christopher C Butler6 1Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, England, UK; 2Centre for Trials Research, Cardiff University, Cardiff, Wales, UK; 3Specialist Antimicrobial Chemotherapy Unit, Microbiology Cardiff, Public Health Wales, Cardiff, Wales, UK; 4School of Population Health and Environmental Sciences, King’s College London, London, England, UK; 5Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 6Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UKCorrespondence: Nick A FrancisPrimary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UKEmail nick.francis@soton.ac.ukIntroduction: Identifying predictors of bacterial and viral pathogens in sputum from patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) may help direct management.Methods: We used data from a trial evaluating a C-reactive protein (CRP) point of care guided approach to managing COPD exacerbations in primary care. We used regression analyses to identify baseline clinical features, including CRP value in those randomized to testing, associated with bacterial, viral or mixed infections, defined by the presence of bacterial and viral pathogens in sputum, detected by culture or polymerase chain reaction (PCR), respectively.Results: Of 386 participants with baseline sputum samples, 79 (20.5%), 123 (31.9%), and 91 (23.6%) had bacterial, viral/atypical, and mixed bacterial/viral/atypical pathogens identified, respectively. Increasing sputum purulence assessed by color chart was associated with increased odds of finding bacterial and mixed (bacterial and viral/atypical) pathogens in sputum (area under the ROC curve (AUROC)

Hasse Melbye,1 Jon Helgeland,2 Øystein Karlstad,3 Inger Ariansen,3 Arnulf Langhammer,4 Torbjørn Wisløff,1 Per Nafstad,3 Wenche Nystad3 1General Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø, Norway; 2Norwegian Institute of Public Health, Division of Health Services, Oslo, Norway; 3Norwegian Institute of Public Health, Department of Non-Communicable Diseases, Oslo, Norway; 4Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, NorwayCorrespondence: Hasse MelbyeGeneral Practice Research Unit, Department of Community Medicine, UIT the Arctic University of Norway, Tromsø 9037, NorwayTel +4795213200Email hasse.melbye@uit.noBackground: Less smoking should lead to fewer COPD cases. We aimed at estimating time trends in the prevalence and burden of COPD in Norway from 2001 to 2017.Methods: We used pre-bronchodilator spirometry and other health data from persons aged 40– 84 years in three surveys of the Tromsø Study, 2001– 2002, 2007– 2008 and 2015– 2016. We applied spirometry lower limits of normal (LLN) according to Global Lung Initiative 2012. Age-standardized prevalence was determined. We defined COPD as FEV1/FVC1 Results: In the Tromsø Study, the age-standardized prevalence of daily smoking dropped from 29.9% to 14.1% among women and from 31.4% to 12.8% among men (P< 0.0001). The age-standardized prevalence of COPD dropped from 7.6% to 5.6% among women (P=0.2) and from 7.3% to 5.6% among men (P=0.003) and of moderate to severe COPD from 5.2% to 2.7% among women (P=0.0003) and from 4.6% to 3.2% among men (P=0.0008). Among men, the yearly age-standardized prevalence of hospitalization due to COPD exacerbation decreased from 3.6 to 3.0 per 1000 inhabitants aged 40– 84 years (P<0.0001). Co