Follow-up of inflammatory markers after initiation of antibiotic therapy in emergency department - comparison of clinical practice and guidelines

master's thesis

• Title (english): Kontrola markera upale nakon početka antibiotske terapije u hitnom prijemu - usporedba prakse i smjernica
• Author: Hana Franić
• Mentor: Ivan Gornik (mentor)
• Committee member: Ivan Gornik (predsjednik povjerenstva)
• Committee member: Marija Bakula (član povjerenstva)
• Committee member: Nadira Duraković (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Department of Gynecology and Obstetrics); Zagreb
• Defense date and country: 2024-07-12, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Gynecology and Obstetrics

Abstract

Inflammatory markers are commonly used laboratory determinants of infective and inflammatory conditions, especially those used in emergency department since they are widely available, affordable, and rapidly interpreted. Therefore, we have investigated CRP values and leukocyte count as two laboratory determinants for initiation of antibiotic therapy, as well as their relative and absolute differences within the 24 hours and effect of those differences on clinical outcome. We believed it was of critical importance to investigate this correlation in the setting of emergency department since that is where most acutely ill patients will initially present, but also due to very scarce and often unclear research that has been done in this subject so far.
Our study included 300 patients, with an average time between first and second CRP sample being 14 ± 6 hours, and the average time between antibiotic initiation and control CRP 11 ± 6 hours. We found no correlation between changes in values and the clinical picture of these patients, both regarding CRP and leukocyte values. This means that whether patients’ condition was declining, improving, or staying the same, CRP control values were not significantly changing respective of those conditions. Regarding CRP control values corelation with clinical outcome, analysis showed statistically significant correlation between changes in absolute and relative CRP values and decision about hospitalization, discharge, observation or change in antibiotic therapy. Second statistical significance was found in case where we compared multiple variables influencing the clinical outcome, and that was that the decision about further treatment did correlate with change in leukocyte count. Since no correlation was found in all other data analysis (for example no correlation was found between clinical picture and clinical outcome), it only proves that clinical practice relies on incorrect assumption that changes in CRP values in less than 24h can correctly direct physician’s decision on further course of treatment including, continuation or change in antibiotic therapy.
We concluded that often unnecessary CRP measurements are done, without any benefit of such practice in the emergency department. CRP samples are taken randomly in a sense that within this 24-hour frame, most controls were taken within half of that time, indicating that physicians might re-check CRP levels just for their reassurance but essentially without those values influencing further treatment of the patient. We believe that data we gathered proved numerous unnecessary controls of CRP, but even more importantly that clinical decisions based on those incorrectly interpreted CRP changes, especially regarding antibiotic treatment, potentially does not benefit these patients.

Abstract (croatian)

Upalni markeri uobičajene su laboratorijske odrednice infektivnih i upalnih stanja, posebice oni koji se koriste u hitnoj službi jer su široko dostupni, pristupačni te se mogu brzo interpretirati. Stoga smo istražili vrijednosti CRP-a i broj leukocita kao dvije laboratorijske odrednice inicijacije antibiotske terapije, njihove relativne i apsolutne razlike unutar 24 sata te učinak tih razlika na klinički ishod. Smatrali smo da je od ključne važnosti istražiti ovu korelaciju u pozadini objedinjenog hitnog prijema jer se tamo inicijalno i javlja većina akutnih bolesnika, ali i zbog vrlo oskudnih i često nejasnih istraživanja koja su do sada provedena na ovu temu.
Ovo istraživanje obuhvatilo je 300 pacijenata, s prosječnim vremenom između prvog i drugog uzorka CRP-a od 14 ± 6 sat, a prosječnim vremenom između početka uzimanja antibiotika i kontrolnog CRP-a 11 ± 6,1 sat. Nismo pronašli korelaciju između promjena vrijednosti i kliničke slike ovih bolesnika, kako u pogledu CRP-a tako i vrijednosti leukocita. To znači da bez obzira na to da li se stanje bolesnika pogoršavalo, poboljšavalo ili ostajalo isto, kontrolne vrijednosti CRP-a nisu se značajno mijenjale u odnosu na ta stanja. Što se tiče korelacije kontrolnih vrijednosti CRP-a s kliničkim ishodom, analiza je pokazala statistički značajnu korelaciju između promjena apsolutnih i relativnih vrijednosti CRP-a i odluke o hospitalizaciji, otpustu, promatranju ili promjeni antibiotske terapije. Druga statistička značajnost ustanovljena je kada smo uspoređivali više varijabli koje utječu na klinički ishod, a to je da je odluka o daljnjem liječenju korelirala s promjenom broja leukocita. Budući da u svim drugim analizama podataka nije pronađena korelacija (na primjer, nije pronađena korelacija između kliničke slike i kliničkog ishoda), to samo dokazuje da se klinička praksa oslanja na pogrešnu pretpostavku da promjene vrijednosti CRP-a u manje od 24 sata mogu ispravno usmjeriti odluku liječnika o daljnjem tijeku liječenja uključujući i nastavak ili promjenu antibiotske terapije.
Zaključili smo da se često rade nepotrebna mjerenja CRP-a, a da takva praksa u objedinjenom hitnom prijemu nema nikakve koristi. Uzorci CRP-a uzimaju se nasumično u smislu da je unutar 24-satnog okvira većina kontrola uzeta unutar polovice tog vremena, što ukazuje da bi liječnici mogli ponovno provjeriti razine CRP-a samo radi vlastite sigurnosti, ali bez da ti rezultati u konačnici utječu na daljnji tijek liječenja. Vjerujemo da su podaci koje smo prikupili dokazali brojne nepotrebne kontrole CRP-a, ali što je još važnije da kliničke odluke temeljene na tim netočno protumačenim promjenama CRP-a, posebice vezane za liječenje antibioticima, potencijalno ne koriste ovim pacijentima.

• Keywords: Inflammatory markers; C reactive protein; Leukocytes; Emergency department; Antibiotic therapy
• Keywords (english): Upalni markeri; C reaktivni protein; leukociti; objedinjeni hitni prijem; antibiotska terapija
• Language: english
• URN:NBN: urn:nbn:hr:105:472145
• Study programme: Title: Medicine (in English language); Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2024-10-18 06:54:26