Pharma Focus Asia

Out-Of-Hours Antibiotic Prescription After Screening With C Reactive Protein: A Randomised Controlled Case Study


Fever, respiratory symptoms and infections are common among children in primary care, especially at out-of-hours (OOH) services. Serious infections have low prevalence in primary care, and even more so after introduction of vaccines for Haemophilus influenzae type B and pneumococcal conjugate vaccines. It is challenging for clinicians to distinguish serious and low-prevalent diseases from common, self-limiting infections.

A severity-of-illness scoring system does not exist for primary care. In Norway, 85% of antibiotics are prescribed in primary care. Despite a decrease in serious infections, the use of antibiotics has been increasing until 2012, and is generally believed to be unnecessarily widespread. Although there has been an increase in methicillin-resistant Staphylococcus aureus (MRSA), the prevalence of antibiotic resistant bacteria is lower than in most other countries.

In order to keep the antimicrobial resistance low, it is important to avoid unnecessary antibiotics and use narrow spectrum penicillin when possible. C reactive protein (CRP) is an inflammation marker, reflecting the severity of inflammation and tissue injury, which is used as a tool to differentiate between bacterial and viral infections.8 It has high popularity in Norwegian primary care as a point-of-care test, and in OOH services it is used in more than half of all children with respiratory symptoms. It thus seems that CRP testing is more like a routine, rather than a supplement to history taking and clinical examination.

The CRP test’s role in ruling out or ruling in serious infections, and the cut-off value for when to prescribe antibiotics has been widely discussed. The impact of CRP as a way of reducing the number of antibiotic prescriptions is at best unclear. The aim of the present study was to evaluate the effect of pre-consultation screening with CRP on antibiotic prescribing and referral to hospital for children aged 0–6 years presenting at OOH services with fever and/or respiratory symptoms.


To evaluate the effect of preconsultation C reactive protein (CRP) screening on antibiotic prescribing and referral to hospital in Norwegian primary care settings with low prevalence of serious infections.

Design & Setting

Randomised controlled observational study at out-of-hours services in Norway’s Primary care.


401 children (0–6 years) with fever and/or respiratory symptoms were recruited from 5 different outof- hours services (including 1 paediatric emergency clinic) in 2013–2015.


Data were collected from questionnaires and clinical examination results. Every third child was randomised to a CRP test before the consultation; for the rest, the doctor ordered a CRP test if considered necessary.

Outcome Measures

Main outcome variables were prescription of antibiotics and referral to hospital.


In the group pretested with CRP, the antibiotic prescription rate was 26%, compared with 22% in the control group. In the group pretested with CRP, 5% were admitted to hospital, compared with 9% in the control group. These differences were not statistically significant. The main predictors for ordering a CRP test were parents’ assessment of seriousness of the illness and the child’s temperature. Paediatricians ordered CRP tests less frequently than did other doctors (9% vs 56%, p<0.001).


Preconsultation screening with CRP of children presenting to out-of-hours services with fever and/or respiratory symptoms does not significantly affect the prescription of antibiotics or referral to hospital.

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