Evaluation of C-Reactive Protein Point of Care Testing, and Associated Research Challenges, to Improve the Quality of Antibiotic Prescribing in the Community in Northern Thailand

Background Antimicrobial resistance (AMR) is a global health challenge, disproportionally affecting low- and middle-income countries (LMICs). Antibiotic use is a key driver of AMR, yet data on their use in LMICs, and in the community where most antibiotics are consumed, are comparatively scarce. C-reactive protein (CRP) is used in some high-income countries to guide antibiotic prescription for community respiratory tract infections (RTIs). Little evaluation has taken place in LMICs. Methods A two year retrospective review of antibiotic use in primary care units (PCUs) across a northern Thai district was conducted. A RCT was carried out in ten Thai and Myanmar primary care clinics evaluating CRP testing to optimise antibiotic use in patients with a history of fever. CRP testing was reviewed in a subgroup with sore throats to determine its ability to identify Group A Streptococcus (GAS) infection. Results Few participants took antibiotics before attending PCUs. RTIs were the commonest infection presentation. Antibiotics appear to be overused in some self-limiting infections. Particularly high proportions were prescribed for sore throats, where the correlations between CRP levels and GAS were poor. In the trial context, CRP testing significantly reduced the proportion of antibiotics prescribed in Thailand and Myanmar, although a non-significant reduction was seen when Thai participants were considered separately. CRP testing improved antibiotic targeting with respect to high CRP levels. Clinical outcomes and health-seeking behaviour during the study period were unaffected. Most healthcare workers and participants supported CRP testing. Conclusions While not uncommon, antibiotic overuse in routine primary care in Thailand was of lower magnitude than anticipated. CRP testing is unlikely to contribute to further large scale reduction in antibiotic prescribing but could better target their use. Identifying who needs antibiotics for sore throats remains challenging. Antimicrobial stewardship interventions in PCUs could have a large impact on prescribing but need to be multi-faceted in nature