title: Early identification of intensive care unit-acquired infections with daily monitoring of C-reactive protein: a prospective observational study.
abstract: BACKGROUND
  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.
  
  
  METHODS
  We undertook a prospective observational cohort study (14 month). All patients admitted for > or =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 < or =8.7 mg/dl and, in the previous days, at least once above the cutoff; and pattern D, CRP always < or =8.7 mg/dl.
  
  
  RESULTS
  CRP 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).
  
  
  CONCLUSIONS
  Daily 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.
authors.affiliation: Unidade de Cuidados Intensivos, Hospital Garcia de Orta, Almada, Portugal. povoap@netcabo.pt
authors.forename: Pedro
authors.initials: P
authors.lastname: Póvoa
authors.forename: Luís
authors.initials: L
authors.lastname: Coelho
authors.forename: Eduardo
authors.initials: E
authors.lastname: Almeida
authors.forename: Antero
authors.initials: A
authors.lastname: Fernandes
authors.forename: Rui
authors.initials: R
authors.lastname: Mealha
authors.forename: Pedro
authors.initials: P
authors.lastname: Moreira
authors.forename: Henrique
authors.initials: H
authors.lastname: Sabino
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism*; D015331:Cohort Studies; D003428:Cross Infection / Q000097:blood* / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D011446:Prospective Studies; D013997:Time Factors
chemical_list: D015415:Biomarkers; D002097:C-Reactive Protein