Septic patients presenting with apparently normal C-reactive protein

Abstract

The presentation of septic patients with low C-reactive protein (CRP) concentrations to the emergency room (ER) might convey an erroneous impression regarding the severity of the disease.We analyzed a retrospective study of septic patients admitted to the internal medicine departments of a relatively large tertiary medical center, following admission to the ER. These patients had CRP concentrations of <31.9 mg/L, the determined cut-off for CRP concentrations in a large cohort of apparently healthy individuals in the community (n = 17,214, upper limit of mean + 3 standard deviations).By processing the electronic medical records, we found 2724 patients with a diagnosis of sepsis, 476 of whom had an admission CRP concentration of <31.9 mg/L. Following further analysis of these records, we found that 34 of the 175 patients (19.4%) who fulfilled the definition of sepsis, died within 1 week of hospitalization. Of special interest was the finding that within <24 h, a significant increment from a median CRP of 16.1 mg/L (IQR 7.9–22.5) to 58.6 mg/L (IQR 24.2–134.4), (P < .001) was noted, accompanied by a velocity change from 0.4 ± 0.29 to 8.3 ± 24.2 mg/L/h following antibiotic administration (P < .001).ER physicians should take into consideration that septic patients with a high in-hospital mortality rate can present with CRP concentrations that are within the range observed in apparently healthy individuals in the community. A second CRP test obtained within 24 h following antibiotic administration might influence attitudes regarding the severity of the disease.

Host Diagnostic Biomarkers of Infection in the ICU: Where Are We and Where Are We Going?

“…One method to improve the diagnostic utility of CRP may be to repeat the test at different time points. Patients presenting early in the illness course may have an increased risk of initial false negative results resulting in delayed treatment initiation that may be associated with a mortality of 19.4% [ 35 , 49 ]. Daily CRP monitoring in ICU patients with an increase of >41 mg/L from the previous day predicted bacterial infection with a sensitivity and specificity of 0.92 and 0.71, respectively, with similar results improving the diagnosis of bacterial versus viral infections [ 50 , 51 ].…”

Development and validation of a prediction model for invasive bacterial infections in febrile children at European Emergency Departments: MOFICHE, a prospective observational study

“…In our study, this intermediate group with diagnostic uncertainty was estimated as 25% of the population of febrile children presenting to the ED, including patients without CRP measurement. Additional diagnostics including procalcitonin, repeated CRP measurement 36 or novel sensitive biomarkers may be helpful in the decision making for this intermediate risk group. The potential benefit of additional diagnostics using these risk thresholds will need to be evaluated in future studies.…”

C-reactive protein velocity discriminates between acute viral and bacterial infections in patients who present with relatively low CRP concentrations

“…Previous studies showed that patients who presented with relatively low CRP values constitute a substantial fraction of the admissions to the emergency department (ED) with acute infectious disease and have a high potential to deteriorate quickly. Wassermann et al showed that 19.4% of patients admitted to ED with relatively low CRP levels (< 31.9 mg/L) and their discharge diagnosis was sepsis, died within 1 week of hospitalization [ 8 ]. Levinson et al presented that 6% of patients diagnosed with gram-negative bacteremia and had an initial low CRP measurement (< 30 mg/L) died within 1 week of hospitalization [ 9 ].…”