Authors (including presenting author) :
Wai AKC(1)(2), Choo KL(3), Cheung LW(4), So JLT(5), Poon HKM(6), Tong CK(7), Wong CKH(8), Hui DSC(9), Rainer TH(1)(2), Butler C(10)
Affiliation :
(1) Accident & Emergency, Queen Mary Hospital
(2) Department of Emergency Medicine, Queen Mary Hospital
(3) Department of Medicine, North District Hospital
(4) Accident & Emergency, Princess Margaret Hospital
(5) Accident & Emergency, Tseung Kwan O Hospital
(6) Accident & Emergency, Tin Shui Wai Hospital
(7) Intensive Care Unit, Tuen Mun Hospital
(8) Department of Pharmacology & Pharmacy, HKU
(9) Department of Medicine & Therapeutics, CUHK
(10) Nuffield Department of Primary Care Health Sciences, The University of Oxford.
Keyword 2: :
Antibiotics Stewardship
Keyword 3: :
C Reactive Protein
Keyword 4: :
Emergency Department
Introduction :
Antimicrobial resistance poses a critical global health threat, exacerbated by antibiotic overuse in acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Bacterial infections cause only 35–57% of AECOPD episodes, yet antibiotics are prescribed in 74–87% of cases. C-reactive protein (CRP) has shown promise in guiding antibiotic stewardship in other settings, but its efficacy in hospital-based AECOPD management across different healthcare contexts remains uncertain.
Objectives :
To determine whether serial CRP-guided antibiotic treatment safely reduces antibiotic exposure for AECOPD patients in Hong Kong emergency and inpatient settings, while maintaining COPD-related health status and evaluating cost-effectiveness.
Methodology :
We conducted a multicentre, single-blind, randomised controlled trial across five Hong Kong Hospital Authority clusters and the University of Hong Kong-Shenzhen Hospital. Adults (aged ≥40 years) with AECOPD were randomly assigned (1:1) to CRP-guided care (intervention; n=128) or usual care (control; n=128). In the intervention group, antibiotic discontinuation was reviewed when CRP fell below 5 mg/dL and patients remained afebrile for 48 hours. Usual care followed standard guidelines without CRP monitoring. The primary outcome was antibiotic duration within 28 days (superiority design). The co-primary outcome was COPD health status measured by the Clinical COPD Questionnaire (CCQ) at 4 weeks (non-inferiority margin: 0.3). Analysis followed intention-to-treat principles.
Result & Outcome :
256 participants were enrolled. No difference in antibiotic duration was observed (median 8 days [IQR 6.75–11] intervention vs 8 days [7–14] control; p = 0.1841). The CRP-guided strategy was non-inferior for COPD health status (median CCQ 2.50 [IQR 1.925–2.90] vs 2.50 [1.90–3.00]; difference 0.0; p = 0.9460). The intervention group had shorter mean hospital stays (5.21 vs 7.01 days; p = 0.029) and lower healthcare costs (HK$27,801 vs HK$36,981 per patient). However, multidrug-resistant organisms were more frequent in the intervention group (10.0% vs 5.3%).
