Intended for healthcare professionals


Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial

BMJ 2009; 338 doi: (Published 05 May 2009) Cite this as: BMJ 2009;338:b1374
  1. Jochen W L Cals, general practitioner trainee and researcher1,
  2. Christopher C Butler, professor of primary care medicine2,
  3. Rogier M Hopstaken, general practitioner and researcher13,
  4. Kerenza Hood, reader in statistics24,
  5. Geert-Jan Dinant, professor of general practice1
  1. 1Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, Netherlands
  2. 2Department of Primary Care and Public Health, School of Medicine, Cardiff University, Wales
  3. 3Foundation of Primary Health Care Centres Eindhoven, Netherlands
  4. 4South East Wales Trials Unit, School of Medicine, Cardiff University, Wales
  1. Correspondence to: J W L Cals j.cals{at}
  • Accepted 16 January 2009


Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.

Design Pragmatic, 2×2 factorial, cluster randomised controlled trial.

Setting 20 general practices in the Netherlands.

Participants 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.

Main outcome measures The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement.

Interventions General practitioners’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.

Results General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days’ follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients’ recovery and satisfaction were similar in all study groups.

Conclusion Both general practitioners’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients’ recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.

Trial registration Current Controlled Trials ISRCTN85154857.


  • We thank Susanne Hanssen, Paula Rinkens, and Ger Driessen (Maastricht) for their support with data collection and the logistics of the study; Mark Kelly (Cardiff) for his assistance with the analysis of the clinical recovery model; and the participating general practitioners and patients.

  • Contributors: CCB and G-JD conceived the study. All authors contributed to the design and implementation of the study. CCB drafted the training in communication skills method. RMH drafted the training in use of C reactive protein testing. JWLC ran the project, wrote the first draft of the manuscript, had full access to all the data in the study, takes responsibility for the integrity of the data and the accuracy of the data analysis, and is guarantor. All authors commented on the first draft and all revisions. KH supervised the development of the analysis plan and the statistical analyses. All authors interpreted the data and findings.

  • Funding: This trial was funded by the Netherlands Organisation for Health Research and Development (grant 945-04010). JWLC is supported by a grant from the Netherlands Organisation for Health Research and Development as a MD-medical research trainee. KH is funded by the Wales Office for Research and Development. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

  • Competing interests: None declared.

  • Ethical approval: This study was approved by the ethics committee of Catherina Hospital in Eindhoven, the Netherlands.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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