Antibiotic prescribing and C-reactive protein testing for pulmonary infections in patients with intellectual disabilities (2024)

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Antibiotic prescribing and C-reactive protein testing for pulmonary infections in patients with intellectual disabilities (1)

The British Journal of General Practice

Br J Gen Pract. 2013 May; 63(610): e326–e330.

Published online 2013 Apr 29. doi:10.3399/bjgp13X667187

PMCID: PMC3635578

PMID: 23643230

Catharina M Peters, MSc, Physician

‘s Heerenloo, Organisation For People With Intellectual Disabilities, Druten;

Francesca M Schouwenaars, MSc, Physician

Oro, Organisation For People With Intellectual Disabilities, Deurne.

Ellen Haagsma, MSc, Physician

Amsta, Organisation For People With Intellectual Disabilities, Amsterdam, The Netherlands.

Heleen M Evenhuis, PhD, Professor

Erasmus University Medical Center, Intellectual Disability Medicine, Rotterdam, The Netherlands.

Michael A Echteld, PhD, Senior researcher, PhD

Erasmus University Medical Center, Intellectual Disability Medicine, Rotterdam, The Netherlands.

Author information Article notes Copyright and License information PMC Disclaimer



Excessive prescribing of antibiotics in patients with lower respiratory tract infections (LRTIs) is common in the general population. Due to communication difficulties, it is hypothesised that prescriptions are even more commonplace in the primary care of individuals with intellectual disabilities. Point-of-care C-reactive protein (POC-CRP) testing might lead to more efficient prescribing of antibiotics.


To evaluate the effect of POC-CRP testing on antibiotic prescriptions for LRTIs by physicians specialising in the care of individuals with intellectual disabilities.

Design and setting

A prospective case-control study in four care centres for individuals with intellectual disabilities in The Netherlands.


Between 27 October 2010 and 27 October 2011, a prospective efficiency study was performed with a base population of 1472 individuals. This population consisted of 882 individuals in whom POC-CRP tests were used and a control group (n = 590) in whom no POC-CRP test was performed.


Of the 48 patients in the control group who were diagnosed as having an LRTI, 43 (90%) received antibiotics, compared with 59 out of the 144 patients (41%) in the case group (OR = 12.0; 95% CI = 4.1–35.3). No significant differences in outcome were found between both groups during a follow-up period of 1 month.


This study shows that the use of POC-CRP testing in patients with intellectual disabilities and LRTIs can lead to a significant reduction in antibiotic prescriptions, with no significant differences in outcome during follow-up.

Keywords: antibiotic prescription, C-reactive protein, intellectual disability, lower respiratory tract infection, point-of-care test


Antibiotics are frequently prescribed in lower respiratory tract infections (LRTIs); this is appropriate for pneumonia or severe exacerbations of chronic obstructive pulmonary disease, but not for acute bronchitis. In the general population, nearly 80% of these respiratory tract infections are caused by acute bronchitis and, therefore, do not require antibiotics.1 Hopstaken et al showed that if respiratory tract infections are suspected following pulmonary auscultation, this, in almost all cases, leads to the prescription of antibiotics; in nearly 80% of cases, this is proved to be unnecessary afterwards.2 Reducing antibiotic prescribing has a number of advantages for individuals as well as the community, including the avoidance of adverse side-effects in patients and reducing resistance development. Furthermore, cost reduction is a possible advantage of a more efficient antibiotic prescribing policy than that which tends to be employed in general practice at present.

Individuals with (severe) intellectual disabilities have a higher risk of developing pneumonia than those without such disabilities, due to higher levels of immobility, gastroesophageal reflux disease, spasticity, scoliosis, and swallowing difficulties.3 Despite this higher risk of developing pneumonia, for which antibiotics are necessary, this group may also be more likely to be prescribed antibiotics unnecessarily. In patients with intellectual disabilities, diagnosing as well as excluding LRTIs may be hampered by communication difficulties so physicians may decide to start antibiotics sooner than they would for patients in the general population. Expectations and pressure from patients, families and caregivers can also lead to antibiotics being prescribed unnecessarily in those with intellectual disabilities.

C-reactive protein

C-reactive protein (CRP) is particularly useful in diagnosing and monitoring bacterial infections.4 The normal serum concentration of CRP is usually <10 mg/L but, in severe bacterial infections, it can rise as high as 500 mg/L.5 In the literature, various cut-off points have been proposed to distinguish between viral and bacterial infections, but there appears to be a consensus that a CRP value of <40 mg/L is suggestive of a viral infection511 and that, in such cases, prescribing antibiotics is not justified.

Point-of-care CRP test

A point-of-care (POC) test is a variant of a laboratory test in which a finger-prick sample is used. Based on data from various studies of the correlation between the POC-CRP test and the laboratory CRP test, it can be said that the agreement between the POC test and the laboratory test is sufficiently large for use in clinical settings.4, 5, 1215

How this fits in

Point-of-care C-reactive protein (POC-CRP) testing has proved to be effective in reducing unnecessary antibiotic prescriptions in general practice. This study shows that using a POC-CRP test in a population with intellectual disabilities leads to an even greater reduction of unnecessary antibiotic prescriptions in comparison with a normal general practice population.

Recently, Cals et al published a study on how POC-CRP testing in LRTIs affects the prescribing of antibiotics in the general population; in the POC-CRP test group, 43.3% of the enrolled patients used antibiotics compared with 56.6% of those in the control group. Patients in the POC-CRP test group recovered as well as patients in the control group.6

This current study aims to evaluate the effect of POC-CRP testing on doctors’ antibiotic prescribing for LRTIs for individuals with an intellectual disability.


Study design


Patients were recruited from four care centres for individuals with intellectual disabilities in The Netherlands. The baseline population consisted of 1472 individuals with an intellectual disability. Primary care was provided by physicians specialising in the care of individuals with learning difficulties. Two of the four centres routinely used CRP testing, the other two did not have a CRP device. The care centres in which a CRP device was available served as the baseline population (n = 882) from which the case group was recruited. The care centres without a CRP device served as the baseline population (n = 590) for the control group.


Between 27 October 2010 and 27 October 2011, all patients with intellectual disabilities and a suspicion of LRTI, determined by clinical assessment, at the four care centres, were prospectively included in the study. Patients who had been prescribed antibiotics in the 2 weeks prior to the first consultation with the physician were excluded. The four care centres all had different patient populations, which varied in terms of average age and level of intellectual disability. To be able to check for selection bias afterwards, the following patient characteristics were recorded on a case form:

  • age (years);

  • sex;

  • level of intellectual disability (mild: IQ between 50–55 to 70; moderate: IQ between 35–40 to 50–55; or severe: IQ below 35–40);

  • use of inhalation medication;

  • wheelchair dependency; and

  • the presence or absence of scoliosis.

The POC-CRP test

The CRP value was determined by using the POC-CRP test. A drop of blood was taken from a patient’s fingertip and collected in a tube; this was then analysed using the NycoCard Reader II. The doctors and physician assistants who performed the tests were aware of correct procedure and analysis techniques. The POC-CRP test took place in the medical service office or at the patient’s bedside.


In this study, no specific criteria for the diagnosis of LRTIs were used. An LRTI was suspected by the physician using routine physical assessment. In this way, the routine practice of diagnosis was not affected in the four care centres.


If antibiotics were prescribed within 28 days after the first consultation, this was noted in the medical records. Any change in antibiotic policy, such as a switch in amount or type, stopping antibiotics prematurely, hospitalisation because of LRTI, or death, was also recorded. At the end of the study, the researchers checked the medical records of each enrolled patient to look for changes in antibiotic prescribing.

Data analysis T

At the end of the study period, all data were collected and clustered in an Excel database. LRTI incidence was calculated for both groups and displayed in percentiles. Patient characteristics (sex, severity of intellectual disability, wheelchair-user status, inhalation medication, and scoliosis) of those in the case and control groups were compared using a χ2-test.

Of all significant (P<0.05) variables, the independent influence on the outcome ‘prescription or no prescription’ was investigated with a logistic regression analysis. The numerical outcome ‘age’ was split into two groups based on the median age of the baseline population. The mean ages in the case and control groups were compared with each other using a t-test.

The incidence of antibiotic prescribing in both groups was presented as a percentage and a 95% confidence interval (CI). Differences in prevalence between the two groups were tested with a χ2-test. The mean CRP value leading to antibiotic prescriptions was calculated and displayed with a range.


Study population

LRTIs were diagnosed in 144 of the 882 (16%) individuals in the case group and in 48 of the 590 (8%) individuals in the control group. The characteristics of the study population are detailed in Table 1. Sex, age, and severity of intellectual disability differed significantly; in the control group the proportion of males was greater (χ2 = 9.6; P = 0.002), the mean age was lower (χ2 = 19.5; P<0.01), and there were more individuals with mild and moderate intellectual disabilities (χ2 = 11.3, P = 0.004) compared with the case group. In both groups, the majority of all patients had a severe intellectual disability.

Table 1

Patient characteristics

TotalCase groupControl groupP-value
  Male, n (%)72 (37.5)45 (31.3)27 (56.3)
  Mean, years (± SD)49.7 (± 20.9)51.0 (± 19.2)37.9 (± 21.0)<0.001
  Range, years0–925–890–92
Level of intellectual disability0.004
  Mild, n (%)19 (9.9)9 (6.3)10 (20.8)
  Moderate, n (%)41 (21.4)28 (19.4)13 (27.1)
  Severe, n (%)132 (68.8)107 (74.3)25 (52.1)
Wheelchair user, n (%)132 (68.8)99 (68.8)33 (68.8)0.702
Scoliosis, n (%)64 (33.3)49 (34.0)15 (31.3)1.000
Inhalation medication, n (%)49 (25.5)34 (23.6)15 (31.3)0.305

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Antibiotic prescribing

There was a significant difference between antibiotic prescribing in the case and control groups (χ2 = 42.2, P<0.005). In the case group, antibiotics were prescribed for 59 of 144 (41%; 95% CI = 33 to 49) patients, whereas in the control group 43 out of 48 individuals (90%; 95% CI = 78 to 96) received a prescription for antibiotics (odds ratio 12.0; 95% CI = 4.1 to 35.3). In the case group, the mean CRP value for prescribing antibiotics was 106.8 mg/L (range: 8–250 mg/L).


There were no significant differences between the case and control groups regarding changes in antibiotic prescriptions during follow-up.

Independent associations with antibiotic prescriptions

Table 2 shows that none of the patient characteristics were significantly and independently associated with the primary outcome of whether or not an individual was prescribed antibiotics.

Table 2

Logistic regression analysis

Odds ratio95% CI
Group (control = 0, case = 1)12.04.1 – 35.3
Sex (male = 0, female = 1)0.800.4 – 1.6
Level of intellectual disability (mild = 0, moderate = 1, severe = 2)1.50.9 – 2.7
Age (below median = 0, median and higher = 1)0.60.3 – 1.2
Reference value = 1

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As far as the authors are aware, this is the first study into the effects of using the POC-CRP test by physicians to aid the decision of whether or not to prescribe antibiotics for LRTIs in individuals with intellectual disabilities. It shows a highly significant difference for antibiotic prescribing in the case group compared with the control group; patients in the control group were significantly more likely to receive antibiotics than patients in the case group. This difference is larger than has been found in general practice populations.6,1617

During the 4 weeks of follow-up, no changes occurred to the initial antibiotics prescription in 83% of patients in the case group and 83% of those in the control group respectively. Differences in patient characteristics between the two groups had no effect on antibiotic prescribing. The mean CRP value at which antibiotics were prescribed well exceeds the limit of 40 mg/L that was used in this study (which was based on published evidence) to distinguish between CRP values consistent with a viral infection and those consistent with a bacterial infection.511

Strengths and limitations

This study has several strengths. It was a multicentre study, in which all physicians within the organisations participated. Moreover, it had a prospective design and the follow-up has been mapped retrospectively. The information transfer to the participating care centres was clear and structured, which increased the reliability of the findings. In addition, carrying out the study did not disturb the common diagnostic practice in the care centres. Nothing appeared to change the way the physicians were already working with regard to diagnosing respiratory tract infections. As such, this study could be seen to accurately reflect the practice in a care centre for individuals with intellectual disabilities.

The study does, however, have some limitations. The number of patients included in the control group was significantly smaller than that of the case group. One explanation for this may be the fact that the base population for the control group was smaller and consisted of a greater proportion of individuals with a mild or moderate disability, compared with the base population for the case group. In addition, selection bias may have occurred. Physicians using the POC-CRP test may rely more on the test than on their own clinical diagnosis; they may diagnose an LRTI sooner in order to conduct a CRP test to be sure whether or not the patient has pneumonia. Moreover, physicians using the POC-CRP test may be more reluctant to prescribe antibiotics than those who do not use the test and, therefore, may use it as a threshold.

The fact that children and adults were included in the study may also indicate a bias; LRTIs in children may have another course of action and a different aetiology.18 The regression analysis showed, however, that age was not an independent risk factor for receiving antibiotics.

Comparison with existing literature

This is the first study into the use of the POC-CRP test in a population with intellectual disabilities. There are some studies that have investigated the use of the POC-CRP test in a general population.6,16,17 Despite the differences of population characteristics between these studies and our current study, it can be concluded that the current study shows a larger difference in antibiotic prescriptions between the case and control groups than studies performed in the general population.

Implications for practice

Although the potential benefits of an effective antibiotic policy are considerable, current antibiotic prescribing by primary care physicians specialising in the care of individuals with learning difficulties could be improved. With a significant global increase in resistance to antibiotics, it is essential that physicians diagnose LRTIs based on a reasonable and objective analysis, such as the POC-CRP test. As a result of the study by Cals et al,6 the POC-CRP test has been included as a complementary investigative method in the Dutch College of General Practitioners’ guideline for acute cough since February 2011.18

The convincing results of this current study on the use of POC-CRP tests by physicians specialising in the care of individuals with learning difficulties encourage the development of a more effective antibiotic policy. Using a POC-CRP test in general practice for individuals with intellectual disabilities in order to identify LRTIs where antibiotics are necessary is, therefore, strongly recommended.


The authors thank all the caregivers and patients of the four participating care centres (Oro in Deurne and Helmond, ‘s Heerenloo in Druten, Tiel and Geldermalsen, Amsta in Amsterdam and Leekerweide in Wognum) who contributed to this study. Thanks also to Dr Ken Redekop for sharing with us his expertise on research methods, and to Dr Harm Boer, for his useful comments on this article.



Not applicable.

Ethical approval

This study was approved by the medical ethical committee of the Erasmus Medical Center, Rotterdam, The Netherlands (reference number: MEC-2010-331).


Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

Discuss this article

Contribute and read comments about this article on the Discussion Forum:


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Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners

Antibiotic prescribing and C-reactive protein testing for pulmonary infections in patients with intellectual disabilities (2024)


Antibiotic prescribing and C-reactive protein testing for pulmonary infections in patients with intellectual disabilities? ›

Conclusion. This study shows that the use of POC-CRP testing in patients with intellectual disabilities and LRTIs can lead to a significant reduction in antibiotic prescriptions, with no significant differences in outcome during follow-up.

What CRP level needs antibiotics? ›

Antibiotic treatment should be routinely offered to patients with symptoms of a lower RTI and a CRP level > 100 mg/L, as they are more likely to have pneumonia, assuming no underlying condition such as malignancy or autoimmune disease is present.

What is the association between antibiotic prescribing for respiratory tract infections and patient satisfaction in direct to consumer telemedicine? ›

In our study of patients with RTIs who accessed care through a direct-to-consumer telemedicine system, 66.1% received a prescription for an antibiotic, which was associated with higher patient satisfaction.

Can CRP detect lung infection? ›

Substantially raised CRP values are usually found in pneumonia,3-6 and a high CRP value has been shown to be a strong predictor for this disease in general practice. However, raised CRP values may also be found in uncomplicated viral respiratory infections, particularly those caused by influenza virus and adenovirus.

What level of CRP indicates bacterial infection? ›

Significantly elevated CRP levels tend to occur with severe infections, such as bacterial or fungal infections. Bacterial infection is responsible for about 90% of the cases involving CRP levels higher than 50 mg/l.

Do antibiotics affect inflammatory markers? ›

These side effects are also extremely variable from patient to patient and from antibiotic to antibiotic. A side effect of antibiotics may paradoxically increase inflammatory marker levels.

Why is CRP not decreasing after antibiotics? ›

If CRP level does not decline within days after initiation of antibiotic therapy, it may be a sign of complicated disease or suggest ineffective antibiotic treatment6.

What are the three 3 guiding principles for prescribing antibiotics? ›

3 Guiding Principles for Prescribing Antibiotics
  • Determine the likelihood of a bacterial infection. Signs and symptoms of bacterial URIs can be similar to those of viral infections. ...
  • Weight the benefits against the harms of antibiotics. ...
  • Implement judicious prescribing strategies.
Nov 26, 2013

Why did my doctor prescribe antibiotics for upper respiratory infection? ›

Most of the time, viruses cause upper respiratory infections. Viruses don't respond to antibiotics. You can most likely treat the symptoms at home through pain relievers, rest and drinking fluids. If you have a bacterial infection, such as strep throat, you'll take antibiotics.

Why should antibiotics never be prescribed for most upper respiratory infections? ›

Acute upper respiratory tract infections (URTIs) are contagious diseases of the upper airways, but they are self-limiting in nature. Therefore, antimicrobial-use for the majority of the URTIs is considered inappropriate.

What happens if high CRP is left untreated? ›

A high level of hs-CRP in the blood has been linked to an increased risk of heart attacks. Also, people who have had a heart attack are more likely to have another heart attack if they have a high hs-CRP level. But their risk goes down when their hs-CRP level is in the typical range.

What kind of inflammation causes high CRP? ›

Results that are greater than 10 milligrams per deciliter (mg/dL) are considered to be high. High levels usually mean you have some kind of inflammation in your body. This might be due to an infection, a serious injury, or an ongoing disease, like inflammatory bowel disease or rheumatoid arthritis.

What does it mean when your C-reactive protein is positive? ›

CRP is a protein that your liver makes. Normally, you have low levels of c-reactive protein in your blood. Your liver releases more CRP into your bloodstream if you have inflammation in your body. High levels of CRP may mean you have a serious health condition that causes inflammation.

What is an alarming CRP? ›

Generally, a CRP level of less than 10 mg/L is considered normal. CRP levels between 10 and 100 mg/L indicate mild to moderate inflammation, while levels above 100 mg/L indicate severe inflammation.

How do you know if your upper respiratory infection is viral or bacterial? ›

A few warning signs that your cold has progressed from a viral infection to a bacterial infection are:
  1. Symptoms lasting longer than 10–14 days.
  2. A fever higher than 100.4 degrees.
  3. A fever that gets worse a couple of days into the illness, rather than getting better.
  4. White pus-filled spots on the tonsils.

What should CRP levels be for antibiotics? ›

The CRP cut-offs used to stop antibiotics were similar and ranged from 10 mg/L to 25 mg/L, while one study reported a cut-off value of 6 mg% (60 mg/L). The comparators used were similar across studies, and the only difference was the minimum duration of antibiotic use (7 days or 14 days of treatment).

What CRP level indicates inflammation? ›

1.0 to 10.0 mg/dL: Moderate elevation (Systemic inflammation such as RA, SLE, or other autoimmune diseases, malignancies, myocardial infarction, pancreatitis, bronchitis). More than 10.0 mg/dL: Marked elevation (Acute bacterial infections, viral infections, systemic vasculitis, major trauma).

How high can CRP levels go in viral infection? ›

The protein is synthesized in the liver and is normally found at concentrations of less than 10 mg/L in the blood. During infectious or inflammatory disease states, CRP levels rise rapidly within the first hours and peak at levels of up to 350–400 mg/L after 48 hours [4].

What is normal CRP despite infection? ›

Our significant finding was that septic patients did indeed present to the ER with CRP concentrations that were completely in the range that can be seen in asymptomatic apparently healthy individuals. ER physicians should, therefore, interpret normal CRP concentrations in the context of sepsis with caution.

How high CRP can be treated? ›

You might be able to reduce your CRP without drugs by: Increasing your aerobic exercise (e.g., running, fast walking, cycling) Quitting smoking. Getting to a weight that supports your health.

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