Abstract
IntroductionManifestations of sepsis are sensitive but are poorly specific of infection. Our aim was to assess the value of daily measurements of C-reactive protein (CRP), temperature and white cell count (WCC) in the early identification of intensive care unit (ICU)-acquired infections.MethodsWe undertook a prospective observational cohort study (14 month). All patients admitted for ≥72 hours (n = 181) were divided into an infected (n = 35) and a noninfected group (n = 28). Infected patients had a documented ICU-acquired infection and were not receiving antibiotics for at least 5 days before diagnosis. Noninfected patients never received antibiotics and were discharged alive. The progression of CRP, temperature and WCC from day -5 to day 0 (day of infection diagnosis or of ICU discharge) was analyzed. Patients were divided into four patterns of CRP course according to a cutoff value for infection diagnosis of 8.7 mg/dl: pattern A, day 0 CRP >8.7 mg/dl and, in the previous days, at least once below the cutoff; pattern B, CRP always >8.7 mg/dl; pattern C, day 0 CRP ≤8.7 mg/dl and, in the previous days, at least once above the cutoff; and pattern D, CRP always ≤8.7 mg/dl.ResultsCRP and the temperature time-course showed a significant increase in infected patients, whereas in noninfected it remained almost unchanged (P < 0.001 and P < 0.001, respectively). The area under the curve for the maximum daily CRP variation in infection prediction was 0.86 (95% confidence interval: 0.752–0.933). A maximum daily CRP variation >4.1 mg/dl was a good marker of infection prediction (sensitivity 92.1%, specificity 71.4%), and in combination with a CRP concentration >8.7 mg/dl the discriminative power increased even further (sensitivity 92.1%, specificity 82.1%). Infection was diagnosed in 92% and 90% of patients with patterns A and B, respectively, and in only two patients with patterns C and D (P < 0.001).ConclusionDaily CRP monitoring and the recognition of the CRP pattern could be useful in the prediction of ICU-acquired infections. Patients presenting maximum daily CRP variation >4.1 mg/dl plus a CRP level >8.7 mg/dl had an 88% risk of infection.
Highlights
Manifestations of sepsis are sensitive but are poorly specific of infection
Daily C-reactive protein (CRP) monitoring and the recognition of the CRP pattern could be useful in the prediction of intensive care unit (ICU)-acquired infections
As CRP measurement is a rapid, reproducible and inexpensive test, the aim of our study was to evaluate whether daily CRP monitoring as well as the assessment of CRP patterns of progression could be useful in the early identification of patients with ICU-acquired infections, in comparison with commonly used markers such as temperature and white cell count (WCC)
Summary
Manifestations of sepsis are sensitive but are poorly specific of infection. Our aim was to assess the value of daily measurements of C-reactive protein (CRP), temperature and white cell count (WCC) in the early identification of intensive care unit (ICU)-acquired infections. Sepsis is defined as the host response to an infection and is characterized by a number of signs such as fever, tachycardia, tachypnea and leukocytosis [4,5] These signs are very sensitive but are poorly specific of infection, can occur in a variety of noninfectious conditions [6,7] and can be influenced by commonly used drugs [8]. A better knowledge of the inflammatory cascade has given new insights and provided several mediators that [9], in conjunction with the clinical manifestations of sepsis, can be APACHE II = Acute Physiology and Chronic Health Evaluation II; AUC = area under the curve; CRP = C-reactive protein; ICU = intensive care unit; IL = interleukin; SIRS = systemic inflammatory response syndrome; SOFA = Sequential Organ Failure Assessment; WCC = white cell count
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