PACE primary care clinician training

Overview of PACE study

Summary

PACE is a randomised controlled trial that aims to evaluate whether using a CRP point of care test (POCT) results in better targeting of antibiotic treatment than usual care informed by NICE (1) and GOLD guidelines (2). The primary outcomes are the overall consumption of antibiotics for COPD and patient-rated clinical recovery from their AECOPD, with the aim being to reduce overall antibiotic use without compromising patient recovery.

Background

The most recent Cochrane review on the use of antibiotics for AECOPD found weak evidence that antibiotic treatment results in benefits for outpatients with AECOPD (3).

Using data from 7 trials and 931 participants, the authors found evidence of a small benefit in terms of reducing treatment failure within 4 weeks (RR 0.75, 95% CI: 0.60, 0.94), but this was not significant reduction when the analysis was restricted to only studies of currently available drugs (RR 0.80, 95% CI: 0.63, 1.01). While it is clear that some patients will benefit from antibiotics, what this review highlights is that many will not.  This makes sense when we think about the aetiology of acute exacerbations - nearly a third are triggered by environmental factors and the majority of infective exacerbations are viral in origin (4, 5).

This is important because unnecessary use of antibiotics can be harmful for patients as well as leading to a general increase in antibiotic resistance, which is one of the most pressing threats that we face as a society (6).
 
There is growing interest in the potential for biomarkers such as C-Reactive Protein (CRP) to help predict benefit from antibiotic treatment for AECOPD (7-9).  High serum CRP is correlated with sputum purulence and increased serum leukocyte counts, and serum CRP is higher in the presence of bacterial infection (9).  A recent primary care trial of antibiotics versus placebo for patients with AECOPD found that antibiotics are only effective in patients who have a high CRP (>40 mg/L) level (10). Similar results were found in a recent trial in a hospital setting (11). However, CRP testing in conjunction with clinical examination for AECOPD in primary care has not yet been evaluated in primary care.

This trial is based on a comprehensive review of evidence including data from our recently published placebo controlled trial of antibiotics for patients with acute exacerbations of COPD (12).