Research Open Access
Like 0



C-reactive protein (CRP) testing can be used as a point-of-care test (POCT) to guide antibiotic use for acute cough.


We wanted to determine feasibility and effect of introducing CRP POCT in general practices in an area with high antibiotic prescribing for patients with acute cough and to evaluate patients’ views of the test.


We used a McNulty–Zelen cluster pragmatic randomised controlled trial design in general practices in Northern England. Eight intervention practices accepted CRP testing and eight control practices maintained usual practice. Data collection included process evaluation, patient questionnaires, practice audit and antibiotic prescribing data.


Eight practices with over 47,000 patient population undertook 268 CRP tests over 6 months: 78% of patients had a CRP < 20 mg/L, 20% CRP 20–100 mg/L and 2% CRP > 100 mg/L, where 90%, 22% and 100%, respectively, followed National Institute for Health and Care Excellence (NICE) antibiotic prescribing guidance. Patients reported that CRP testing was comfortable (88%), convenient (84%), useful (92%) and explained well (85%). Patients believed CRP POCT aided clinical diagnosis, provided quick results and reduced unnecessary antibiotic use. Intervention practices had an estimated 21% reduction (95% confidence interval: 0.46–1.35) in the odds of prescribing for cough compared with the controls, a non-significant but clinically relevant reduction.


In routine general practice, CRP POCT use was variable. Non-significant reductions in antibiotic prescribing may reflect small sample size due to non-use of tests. While CRP POCT may be useful, primary care staff need clearer CRP guidance and action planning according to NICE guidance.


Article metrics loading...

Loading full text...

Full text loading...



  1. Public Health England (PHE). English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). Report 2018. London: PHE; 2018. Available from: https://allcatsrgrey.org.uk/wp/download/public_health/ESPAUR_2018_report.pdf
  2. National Institute for Health and Care Excellence (NICE). Respiratory tract infections (self-limiting): prescribing antibiotics. Clinical guideline [CG69]. London: NICE; 23 Jul 2008. Available from: https://www.nice.org.uk/guidance/cg69
  3. Smieszek T, Pouwels KB, Dolk FCK, Smith DRM, Hopkins S, Sharland M, et al. Potential for reducing inappropriate antibiotic prescribing in English primary care. J Antimicrob Chemother. 2018;73(suppl_2):ii36-43.  https://doi.org/10.1093/jac/dkx500  PMID: 29490058 
  4. Little P, Stuart B, Moore M, Coenen S, Butler CC, Godycki-Cwirko M, et al. Amoxicillin for acute lower-respiratory-tract infection in primary care when pneumonia is not suspected: a 12-country, randomised, placebo-controlled trial. Lancet Infect Dis. 2013;13(2):123-9.  https://doi.org/10.1016/S1473-3099(12)70300-6  PMID: 23265995 
  5. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database Syst Rev. 2014;3(3):CD000245.  https://doi.org/10.1002/14651858.CD000245.pub3  PMID: 24585130 
  6. Department of Health. UK five-year antimicrobial resistance strategy 2013 to 2018. London: Department of Health; 2013. Available from: https://www. gov.uk/ government/ uploads/system/ uploads/ attachment_ data/ file/ 244058/ 20130902_ UK_ 5_ year_AMR_ strategy.pdf
  7. O’Niell J. 2016. Review on antimicrobial resistance. London: UK Department of Health; May 2016. Available from: https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf
  8. National Institute for Health and Care Excellence (NICE). Pneumonia in adults: diagnosis and management. Clinical guideline [CG191]. London: NICE; 2014.Available from: https://www.nice.org.uk/guidance/cg191/resources/pneumonia-in-adults-diagnosis-and-management-35109868127173
  9. National Institute for Health and Care Excellence (NICE). Cough (acute): antimicrobial prescribing. London: NICE; Feb 2019. Available from: https://www.nice.org.uk/guidance/ng120/resources/visual-summary-pdf-6664861405
  10. Oppong R, Coast J, Hood K, Nuttall J, Smith RD, Butler CC, et al. Resource use and costs of treating acute cough/lower respiratory tract infections in 13 European countries: results and challenges. Eur J Health Econ. 2011;12(4):319-29.  https://doi.org/10.1007/s10198-010-0239-1  PMID: 20364288 
  11. Huang Y, Chen R, Wu T, Wei X, Guo A. Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies. Br J Gen Pract. 2013;63(616):e787-94.  https://doi.org/10.3399/bjgp13X674477  PMID: 24267862 
  12. Joshi A, Perin DP, Gehle A, Nsiah-Kumi PA. Feasibility of using C-reactive protein for point-of-care testing. Technol Health Care. 2013;21(3):233-40.  https://doi.org/10.3233/THC-130720  PMID: 23792796 
  13. Engel MF, Paling FP, Hoepelman AI, van der Meer V, Oosterheert JJ. Evaluating the evidence for the implementation of C-reactive protein measurement in adult patients with suspected lower respiratory tract infection in primary care: a systematic review. Fam Pract. 2012;29(4):383-93.  https://doi.org/10.1093/fampra/cmr119  PMID: 22159030 
  14. Petel D, Winters N, Gore GC, Papenburg J, Beltempo M, Lacroix J, et al. Use of C-reactive protein to tailor antibiotic use: a systematic review and meta-analysis. BMJ Open. 2018;8(12):e022133.  https://doi.org/10.1136/bmjopen-2018-022133  PMID: 30580258 
  15. Cals JW, Butler CC, Hopstaken RM, Hood K, Dinant GJ. Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. BMJ. 2009;338(may05 1):b1374.  https://doi.org/10.1136/bmj.b1374  PMID: 19416992 
  16. Cals JW, Chappin FH, Hopstaken RM, van Leeuwen ME, Hood K, Butler CC, et al. C-reactive protein point-of-care testing for lower respiratory tract infections: a qualitative evaluation of experiences by GPs. Fam Pract. 2010;27(2):212-8.  https://doi.org/10.1093/fampra/cmp088  PMID: 20022909 
  17. Hughes A, Gwyn L, Harris S, Clarke C. Evaluating a point-of-care C reactive protein test to support antibiotic prescribing decisions in a general practice. Clin Pharm. 2016;8(10):309-8.
  18. Eley CV, Sharma A, Lecky DM, Lee H, McNulty CAM. Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England. BMJ Open. 2018;8(10):e023925.  https://doi.org/10.1136/bmjopen-2018-023925  PMID: 30361406 
  19. McNulty C, Ricketts EJ, Rugman C, Hogan A, Charlett A, Campbell R, et al. A qualitative study exploring the acceptability of the McNulty-Zelen design for randomised controlled trials evaluating educational interventions. BMC Fam Pract. 2015;16(69):169.  https://doi.org/10.1186/s12875-015-0356-0  PMID: 26577832 
  20. National Institute for Health and Care Excellence (NICE). Alere Afinion CRP for C-reactive protein testing in primary care. London: NICE; 14 Sep 2016. Available from: https://www.nice.org.uk/advice/mib81/resources/alere-afinion-crp-for-creactive-protein-testing-in-primary-care-pdf-63499402887109
  21. Ward C. Point-of-care C-reactive protein testing to optimise antibiotic use in a primary care urgent care centre setting. BMJ Open Qual. 2018;7(4):e000391.  https://doi.org/10.1136/bmjoq-2018-000391  PMID: 30397661 
  22. Abbott. Alere Afinion CRP. Warrington: Abbott. [Accessed: Sep 2018]. Available from: https://www.alere.com/en/home/product-details/afinion-crp.html
  23. NHS Health Research Authority. Is my study research?. London: NHS Health Research Authority. [Accessed: 28 Apr 2017]. Available from: http://www.hra.nhs.uk/documents/2016/06/defining-research.pdf
  24. Cals JWL, de Bock L, Beckers PJHW, Francis NA, Hopstaken RM, Hood K, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory tract infection: 3.5-year follow-up of a cluster randomized trial. Ann Fam Med. 2013;11(2):157-64.  https://doi.org/10.1370/afm.1477  PMID: 23508603 
  25. Wood F, Brookes-Howell L, Hood K, Cooper L, Verheij T, Goossens H, et al. A multi-country qualitative study of clinicians’ and patients’ views on point of care tests for lower respiratory tract infection. Fam Pract. 2011;28(6):661-9.  https://doi.org/10.1093/fampra/cmr031  PMID: 21653924 
  26. Tonkin-Crine S, Anthierens S, Francis NA, Brugman C, Fernandez-Vandellos P, Krawczyk J, et al. Exploring patients’ views of primary care consultations with contrasting interventions for acute cough: a six-country European qualitative study. NPJ Prim Care Respir Med. 2014;24(1):14026.  https://doi.org/10.1038/npjpcrm.2014.26  PMID: 25030621 
  27. Rebnord IK, Hunskaar S, Gjesdal S, Hetlevik Ø. Point-of-care testing with CRP in primary care: a registry-based observational study from Norway. BMC Fam Pract. 2015;16(170):170.  https://doi.org/10.1186/s12875-015-0385-8  PMID: 26585447 
  28. Cooke J, Butler C, Hopstaken R, Dryden MS, McNulty C, Hurding S, et al. Narrative review of primary care point-of-care testing (POCT) and antibacterial use in respiratory tract infection (RTI). BMJ Open Respir Res. 2015;2(1):e000086.  https://doi.org/10.1136/bmjresp-2015-000086  PMID: 25973210 

Data & Media loading...

Supplementary data

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error