You may be interested to know that according to the Daily Telegraph, during winter 2022, there were nearly 15,000 excess deaths associated with flu, the highest figure since 2017-18 when 22,500 more people died.

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Followers of Smokescreens will recognise this statement for what it is: a dense curtain of thick oily smoke screening something else. It looks like Jellicoe’s destroyers are screening the Grand Fleet at Jutland. Is that not the case?

Let us start by assuming that the F word here is used as synonymous with influenza. We have good reasons for our interpretation because the article was not about how many excess deaths the media have decided are attributable to the F word. 

The piece was about another miracle: the commercialisation of a lateral flow type test that can identify influenza (hence our interpretation of the F word) and Covid in 30 minutes or so. These quickies are known as point-of-care tests. According to the Telegraph piece, using this test will allow your GP to prescribe antivirals (or not) and, most of all, not throw antibiotics at anyone with suspected pneumonia.

You see, the media and the test manufacturers think antibiotic use is a bad idea in suspected pneumonia, given the onset of resistance and the cost. 

Let’s think about that. Cost and resistance are issues that apply equally to antivirals and antibiotics. However, there is no evidence that oral influenza antivirals make any difference to lower respiratory tract infections (LRTI), whereas antibiotics do.

Another subtle distortion is the assumption that influenza infection is directly responsible for pneumonia. Smokescreens readers know that viral pneumonia is a rare occurrence, although it may be an (or the) underlying cause of the real grim reaper: bacterial pneumonia followed by respiratory failure.

We know from bitter personal experience that withholding antibiotics in suspected pneumonia (in this case, post measles) in vulnerable symptomatic people is an awful decision.

The whole piece hinges on the rapidity of the test and the possibility of prescribing the “right stuff”—thirty minutes, as opposed to 2 days for a PCR result to come back. Remember, antivirals must be administered within two days of symptom onset to shorten the duration of symptoms by a few hours - the only real documented benefit.

What the piece hides behind the thick oily curtain is that a cheap point-of-care test for C reactive protein (CRP) is a much better, cheaper and more effective alternative. 

CRP is an aspecific indicator of inflammation. However, its use in 6 of the 11 nursing homes in a cluster randomised trial in Holland led to a 30% decrease in antibiotic prescription in elderly with suspected LRTIs compared to no use. 

The odds of full recovery at three weeks and mortality and hospital admission at any point did not significantly differ between the CRP and standard case nursing home clusters. So, they did not kill anyone by using CRP to guide their decisions.

CRP is cheap at around £10 a test and cost-effective if used following guidelines on managing suspected LRTI. 

So, while CRP is helpful in the clinical management of adults and children as an effective strategy for targeting antibiotics, its use is largely ignored for the golden triangle of F-word tests. So, why would you want to do that, and why would you write an article hyping new tests when there’s a better, cheaper, evidence-based alternative? 

How’s that for a smokescreen?

Readings

Factors Associated With the Development of Bacterial Pneumonia Related to Seasonal Influenza Virus Infection: A Study Using a Large-scale Health Insurance Claim Database, Open Forum Infectious Diseases, Volume 10, Issue 5, May 2023, ofad222, https://doi.org/10.1093/ofid/ofad222

Effect of C reactive protein point-of-care testing on antibiotic prescribing for lower respiratory tract infections in nursing home residents: a cluster randomised controlled trial  BMJ  2021;  374 :n2198 doi:10.1136/bmj.n2198

Cost-Effectiveness Analysis of the Use of Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing in Primary Care. Antibiotics (Basel). 2018 Dec 7;7(4):106. doi: 10.3390/antibiotics7040106.