title: Characteristics of neonates with culture-proven bloodstream infection who have low levels of C-reactive protein (≦10 mg/L).
abstract: BACKGROUND
  Elevated C-reactive protein (CRP) level is widely used in clinical practice as a marker to distinguish between neonates with or without sepsis. However, some neonates with bacteremia have a CRP level within the normal range and they are not well characterized.
  
  
  METHODS
  All episodes of neonatal culture-proven bloodstream infections (BSIs) between July 2004 and June 2012 were enrolled. Patients characteristics were compared for three CRP groups (low, ≤ 10 mg/L; intermediate, 11-100 mg/L; and high, > 100 mg/L) using the Chi-square test and one-way ANOVA. The sepsis-attributable mortality rates were compared using logistic regression analyses.
  
  
  RESULTS
  Of 986 episodes of neonatal BSI, 247 (25.1 %) had CRP ≤10 mg/L at the onset of clinical sepsis. In the low CRP group, patients had lower gestational age and birth weight, and an earlier occurrence of BSI. Patients with underlying gastrointestinal pathology, renal disorders, cholestasis, and pulmonary hypertension had a non-significant elevated CRP level at the onset of sepsis. In the blood culture of the low CRP group, coagulase-negative staphylococci (CoNS) were relatively more common (55.9 %, p < 0.001) than the other two groups, although one-fourth were infected with gram-negative bacilli (19.0 %), fungi (2.8 %), or polymicrobial pathogens (3.6 %). Of the BSIs with initial low CRP, 29.1 % were treated with inadequate antibiotics, 13.0 % progressed to septic shock, and 5.3 % had infectious complications. The sepsis-attributable mortality rate was lower in the low CRP group (4.9 %) than in the high CRP group (13.6 %).
  
  
  CONCLUSIONS
  A considerable proportion of neonatal BSIs had a normal or low initial CRP level (≤10 mg/L), which was more likely to occur in low birth weight or extremely preterm infants, those with earlier onset of sepsis, and those infected with CoNS. Plasma CRP level should not be used to rule out severe culture-proven sepsis or guide the empirical choice of antibiotics.
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. lmi818@msn.com.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. lmi818@msn.com.
authors.forename: Mei-Yin
authors.initials: MY
authors.lastname: Lai
authors.affiliation: Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan. mingmin.tw@yahoo.com.tw.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. mingmin.tw@yahoo.com.tw.
authors.forename: Ming-Horng
authors.initials: MH
authors.lastname: Tsai
authors.affiliation: Department of Nursing, Division of Basic Medical Sciences, and Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chia-Yi, Taiwan. cwlee@gw.cgust.edu.tw.|Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan. cwlee@gw.cgust.edu.tw.
authors.forename: Chiang-Wen
authors.initials: CW
authors.lastname: Lee
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. cmc123@cgmh.org.tw.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. cmc123@cgmh.org.tw.
authors.forename: Ming-Chou
authors.initials: MC
authors.lastname: Chiang
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. reyinl@cgmh.org.tw.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. reyinl@cgmh.org.tw.
authors.forename: Reyin
authors.initials: R
authors.lastname: Lien
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. rkenny@cgmh.org.tw.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. rkenny@cgmh.org.tw.
authors.forename: Ren-Huei
authors.initials: RH
authors.lastname: Fu
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. qbonbon@gmail.com.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. qbonbon@gmail.com.
authors.forename: Hsuan-Rong
authors.initials: HR
authors.lastname: Huang
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. kz6479@cgmh.org.tw.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. kz6479@cgmh.org.tw.|Linkou Chang Gung Memorial Hospital, No. 5, Fu-Shin Rd., Kwei-Shan, Taoyuan, Taiwan. kz6479@cgmh.org.tw.
authors.forename: Shih-Ming
authors.initials: SM
authors.lastname: Chu
authors.affiliation: Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. jeff0724@gmail.com.|College of Medicine, Chang Gung University, Taoyuan, Taiwan. jeff0724@gmail.com.|Linkou Chang Gung Memorial Hospital, No. 5, Fu-Shin Rd., Kwei-Shan, Taoyuan, Taiwan. jeff0724@gmail.com.
authors.forename: Jen-Fu
authors.initials: JF
authors.lastname: Hsu
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016470:Bacteremia / Q000188:drug therapy; D001430:Bacteriocins / Q000302:isolation & purification / Q000378:metabolism; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis*; D003030:Coagulase / Q000172:deficiency / Q000378:metabolism; D005260:Female; D005658:Fungi / Q000302:isolation & purification; D005865:Gestational Age; D006090:Gram-Negative Bacteria / Q000302:isolation & purification; D006094:Gram-Positive Bacteria / Q000302:isolation & purification; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D007363:Intensive Care Units, Neonatal; D016015:Logistic Models; D008297:Male; D018805:Sepsis / Q000175:diagnosis* / Q000382:microbiology / Q000401:mortality; D015996:Survival Rate
chemical_list: D000900:Anti-Bacterial Agents; D001430:Bacteriocins; D015415:Biomarkers; D003030:Coagulase; C017724:staphylococcin; D002097:C-Reactive Protein