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Isaeva E, Akylbekov A, Bloch J, Poulsen A, Kurtzhals J, Siersma V, Sooronbaev T, Aabenhus RM, Kjærgaard J. The Feasibility of C-Reactive Protein Point-of-Care Testing to Reduce Overuse of Antibiotics in Children with Acute Respiratory Tract Infections in Rural Kyrgyzstan: A Pilot Study. Pediatric Health Med Ther 2024; 15:67-76. [PMID: 38371485 PMCID: PMC10874192 DOI: 10.2147/phmt.s425095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/30/2023] [Indexed: 02/20/2024] Open
Abstract
Background In Kyrgyzstan, the morbidity prevalence of and morbidity from acute respiratory tract infections (ARTI) in children is high. Local healthcare workers (HCW) often prescribe antibiotics that are not indicative due to a mix of professional and societal factors. It is suggested to precede with a decision on antibiotics by a point-of-care test (POCT) on the appropriateness of the treatment, eg, a measurement of C-reactive protein (CRP). CRP-guided antibiotic stewardship in children with ARTI has not previously been studied in Central Asia. Purpose This pilot study was conducted to examine the feasibility of the methods and procedures to be used in the upcoming randomised controlled COORDINATE clinical trial (NCT05195866) and in daily clinical practice in primary care. Patients and methods HCWs from three selected rural healthcare facilities were trained in the CRP POCT and in interpretation of results. Children aged 6 months to 12 years attending the primary healthcare facilities with respiratory symptoms were randomly assigned to CRP-guided management or standard care, guided by clinical findings only. Children were followed up for 14 days by scheduled telephone calls to caregivers. Results Eighty-one children participated in this pilot study. The CRP POCT and the trial procedures were acceptable to the target group as well as to the HCWs. Children from both groups recovered equally well, with an observed significant lower use of antibiotics in the CRP group. HCWs generally adhered to the CRP guidelines, and only once was an antibiotic prescribed despite low CRP results. No safety concerns were observed. Four parents provided wrong phone numbers impeding follow-up. We will collect all mobile phone numbers in the household for the main trial. Conclusion The pilot provided satisfactory results, suggesting that the COORDINATE trial of CRP POCT is effective, feasible with minor adjustments and without apparent safety concerns for the participants.
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Affiliation(s)
- Elvira Isaeva
- Allergology Department, National Centre of Maternity and Childhood Care (NCMCC), Bishkek, Kyrgyzstan
| | - Azamat Akylbekov
- Pulmonology Department, National Centre of Cardiology and Internal Medicine Named After Academician M. Mirrakhimov, Bishkek, Kyrgyzstan
| | - Joakim Bloch
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anja Poulsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Kurtzhals
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Talant Sooronbaev
- Pulmonology Department, National Centre of Cardiology and Internal Medicine Named After Academician M. Mirrakhimov, Bishkek, Kyrgyzstan
| | - Rune Munck Aabenhus
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjærgaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Qi JF, Guo ML, Lin L, Fu S, Chen LL. An exploration of the value of NLR, PLR, LMR, and WBC × CRP for the diagnosis and treatment of influenza B in adults. Medicine (Baltimore) 2024; 103:e37046. [PMID: 38306568 PMCID: PMC10843311 DOI: 10.1097/md.0000000000037046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024] Open
Abstract
The aim of the study was to study the diagnostic and therapeutic utility of NLR (neutrophil-to-lymphocyte ratio), LWR (lymphocyte-to-monocyte ratio), PLR (platelet-to-lymphocyte ratio), and WBC × CRP (WBC: white cell count, CRP: C-reactive protein) in patients with influenza B. This retrospective study included 122 adult patients with influenza B, 176 adult patients with bacterial infection, and 119 adult healthy physical examinees for routine blood examination and CRP testing, calculation of NLR, LMR, PLR, and WBC × CRP for relevant statistical analysis, monitoring of NLR, LMR, PLR and WBC × CRP in patients with influenza B during relevant treatment. All indicators, except for WBC and NLR, had no statistical differences between the influenza B group, the normal control group, and the influenza B group and bacterial infection group, respectively, and showed no statistical significance for the differences between the groups. The diagnostic effect of LMR and WBC × CRP was deemed good or excellent in patients with influenza B, healthy people, and patients with a bacterial infection. Conversely, NLR and PLR could only distinguish patients with influenza B from healthy people but remained unable to identify different pathogens. Moreover, many false negatives were noted for WBC and CRP during the diagnosis of influenza B. Also, NLR, LMR, PLR, and WBC × CRP exerted a good effect in evaluating curative effect and conditions for influenza B. LMR and WBC × CRP have a relatively high value in the early diagnosis of adults suffering from influenza B. Also, NLR and PLR excelled at differentiating adult patients with influenza B from healthy people. Therefore, NLR, PLR, LMR, and WBC × CRP can all be used for disease course monitoring and efficacy evaluation.
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Affiliation(s)
- Juan-Fei Qi
- Department of Clinical Laboratory, Xinchang Hospital of traditional Chinese (MD) Medicine, Shaoxing, Zhejiang Province, People’s Republic of China
| | - Mei-Li Guo
- Department of Clinical Laboratory, The People’s Hospital of Cangnan Zhejiang, Wenzhou, Zhejiang Province, People’s Republic of China
| | - Li Lin
- Department of Rehabilitation, Taizhou Hospital of Zhejiang Province, Taizhou, Zhejiang province, People’s Republic of China
| | - Shui Fu
- Department of Clinical Laboratory, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang Province, People’s Republic of China
| | - Liu-Ling Chen
- Department of Clinical Laboratory, Xinchang Hospital of traditional Chinese (MD) Medicine, Shaoxing, Zhejiang Province, People’s Republic of China
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Cohen N, Feigin E, Berliner S, Zeltser D, Witztum T, Goldiner I, Shtark M, Shenhar-Tsarfaty S, Ziv-Baran T, Matsri S, Hashavia E. Early signaling of inflammation in patients following traumatic injury with accurately estimated time of injury by profiling C-reactive protein levels. Clin Chim Acta 2023; 550:117580. [PMID: 37778680 DOI: 10.1016/j.cca.2023.117580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Despite its widespread use, the precise dynamics of CRP response in clinical practice remain poorly defined. We employed a novel quadratic model to explore the time-course analysis of CRP values in trauma patients with known precise time of injury. METHODS Relevant data on all adult patients admitted to our hospital following traumatic incidents between January 1st 2010 to December 31, 2020 were retrospectively collected. Those with a documented time of injury and who underwent CRP evaluation within the first 24 h since injury were studied. RESULTS Based on the findings from our annual health check-up center, we established a reference upper normal CRP value of 12.99 mg/L. Within the first 7 h after injury, the CRP levels of 8-9% of the 1545 study patients exceeded the reference threshold. The proportion of patients with CRP levels > 12.99 mg/L increased to 18.5% at 8-9 h later and rose sharply to 91.6% at 22-24 h later. Our quadratic model yielded the equation: CRP = 5.122-0.528xTime + 0.139xTime 2. It accounted for > 40% of the variance in CRP levels (R2 = 42.4%). CONCLUSIONS Clear and prominent CRP elevations following atraumatic event are detected only 9-12 h following the insult. This novel finding has crucial implications for accurate CRP assessment of inflammatory responses to physical injuries.
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Affiliation(s)
- Neta Cohen
- Emergency Department, Tel Aviv Sourasky Medical Center, Tel Aviv-Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Eugene Feigin
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Israel; Departments of Internal Medicine C", D" and E", Tel Aviv Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Berliner
- Departments of Internal Medicine C", D" and E", Tel Aviv Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Zeltser
- Emergency Department, Tel Aviv Sourasky Medical Center, Tel Aviv-Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Witztum
- Departments of Internal Medicine C", D" and E", Tel Aviv Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilana Goldiner
- Division of Clinical Laboratories, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Moshe Shtark
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Israel; Division of Clinical Laboratories, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Shani Shenhar-Tsarfaty
- Departments of Internal Medicine C", D" and E", Tel Aviv Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sher Matsri
- Departments of Internal Medicine C", D" and E", Tel Aviv Sourasky Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Hashavia
- Division of Trauma, Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Plebani M. Why C-reactive protein is one of the most requested tests in clinical laboratories? Clin Chem Lab Med 2023; 61:1540-1545. [PMID: 36745137 DOI: 10.1515/cclm-2023-0086] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/07/2023]
Abstract
C-reactive protein (CRP) is an acute-phase protein which is synthesized by the liver in response to the secretion of several inflammatory cytokines including interleukin 6 (IL-6), IL-1 and tumor necrosis factor (TNF). CRP was the first acute-phase protein to be described and adopted in clinical laboratories as an exquisitely sensitive systemic marker of inflammation and tissue damage. The measurement of CRP is widely used for the diagnosis and monitoring of inflammatory conditions, including sepsis, trauma, and malignancies. In the last decades, impressive advances in analytical methods (from qualitative to high-sensitivity assays), automation and availability of results in a short time, not only translated in an increasing demand for the right management of systemic inflammatory diseases, but also in evaluating subclinical inflammatory processes underlying atherothrombotic events. CRP measurement is one of the most requested laboratory tests for both the wide range of clinical conditions in which it may assure a valuable information and some analytical advantages due to the evidence that it is a "robust biomarker". Even recently, the measurement of CRP received new interest, particularly as a biomarker of severity of Coronavirus disease 2019 (COVID-19), and it deserves further concern for improving demand appropriateness and result interpretation.
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Affiliation(s)
- Mario Plebani
- Clinical Biochemistry and Clinical Molecular Biology, University of Padova, Padova, Italy
- Department of Pathology, University of Texas, Galveston, USA
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Feigin E, Levinson T, Witztum T, Adler A, Goldiner I, Egoz E, Rogowski O, Meilik A, Zeltser D, Shapira I, Shenhar-Tsarfaty S, Berliner S, Wasserman A. Early signaling of bacteremia in patients who present to the Department of Emergency Medicine with relatively low C-Reactive Protein (CRP) concentrations. Clin Chim Acta 2023:117451. [PMID: 37336422 DOI: 10.1016/j.cca.2023.117451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Examiningthe usefulness of C-reactive protein velocity (CRPv) as an early biomarker for the presence of bacteraemia in patients presenting to the Department of Emergency Medicine with acute infection/inflammation and suspected bacteraemia. METHODS A retrospective study examining a cohort of patients who presented to the E.R and in whom blood cultures were taken. CRPv was calculated as the difference in mg/hour/litter between two consecutive CRP tests performed within 12 hours. RESULTS 256 patients were included in the cohort. Using CRPv in patients who at first presented with a relatively low (17.9≤mg/L 1stquartile) CRP concentration, we found an AUC of 0.808±0.038 (p<0.001) for the presence of positive versus negative blood cultures (what is AUC?). This was better than the AUC that was obtained when the WBC for the same purpose. CONCLUSIONS CRPv may be a useful biomarker in the identification of patients with suspected bacteremiaand a low CRP-a challenging situation for clinicians who may underestimate the severity of illness in this patient group.
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Affiliation(s)
- Eugene Feigin
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Tal Levinson
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; Infectious Diseases Unit, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Tamar Witztum
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Amos Adler
- Microbiology Laboratory, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Ilana Goldiner
- Laboratory Medicine, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
| | - Eyal Egoz
- I-Medata AI Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel.
| | - Ori Rogowski
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Ahuva Meilik
- I-Medata AI Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel.
| | - David Zeltser
- Department of Emergency medicine, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Itzhak Shapira
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Shani Shenhar-Tsarfaty
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Shlomo Berliner
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
| | - Asaf Wasserman
- Department of Internal Medicine "C", "D", & "E", Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel.
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Discrepancy of C-Reactive Protein, Procalcitonin and Interleukin-6 at Hospitalization: Infection in Patients with Normal C-Reactive Protein, Procalcitonin and High Interleukin-6 Values. J Clin Med 2022; 11:jcm11247324. [PMID: 36555941 PMCID: PMC9783053 DOI: 10.3390/jcm11247324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
C-reactive protein (CRP) or procalcitonin (PCT) alone has limitations in the early detection of infection or inflammation due to shortcomings in specificity and varied cut-off values. Recently, interleukin (IL)-6 has been assessed, but it is not known to what extent the three values are homogeneous in reality. This retrospective study was conducted with two large datasets (discrepancy set with results within 24 h of admission [7149 patients] and follow-up set until 2 weeks of hospital stay [5261 tests]) consisting of simultaneous examinations of CRP, PCT, and IL-6 between January 2015 and August 2021. The specific discrepant group (n = 102, 1.4%) with normal CRP (<10 mg/L) and PCT (<0.1 ng/mL) and high IL-6 (≥100 pg/mL) values was extracted from the discrepancy set. Dimensionality reduction and visualization were performed using Python. The three markers were not clearly clustered after t-distributed stochastic neighbor embedding. Pearson’s correlation coefficients between two markers were substantially low (0.23−0.55). Among the high normalized IL-6 levels (≥0.5) (n = 349), 17.8% and 38.7% of CRP and PCT levels were very low (≤0.01). 9.2% and 13.4% of normal CRP (n = 1522) had high PCT (≥0.5 ng/mL) and IL-6 (≥100 pg/mL) values, respectively. Infection and bacteremia among 102 patients occurred in 36 (35.3%) and 9 (8.8%) patients, respectively. In patients with bacteremia, IL-6 was the first to increase, followed by PCT and CRP. Our study revealed that CRP, PCT, and IL-6 levels were considerably discrepant, which could be misinterpreted if only CRP tests are performed.
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Bouzid D, Debray MP, Choquet C, de Montmollin E, Roussel M, Ferré V, Thy M, Le Hingrat Q, Loubet P. Diagnostic des pneumonies aiguës communautaires aux urgences et distinction entre étiologie virale ou bactérienne. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
La pandémie actuelle liée à l’émergence du SARSCoV-2 en 2019 a considérablement modifié la perception des médecins de l’impact des virus respiratoires et de leur rôle dans les pneumonies aiguës communautaires (PAC). Alors que plus de 25 % des tableaux de PAC chez l’adulte étaient d’origine virale, les virus respiratoires étaient souvent perçus comme des agents pathogènes peu graves. Devant le défi que représente encore à nos jours la documentation microbiologique d’une PAC, l’instauration d’un traitement empirique par antibiotiques est souvent réalisée aux urgences. La pandémie de COVID-19 a surtout mis en exergue le rôle déterminant de la biologie moléculaire et du scanner thoracique dans l’algorithme diagnostique de la PAC. En effet, un diagnostic rapide et fiable est la clé pour améliorer les mesures de précaution et réduire la prescription inutile d’antibiotiques. Du fait de prises en charges très différentes, il est nécessaire de distinguer l’étiologie virale de la bactérienne d’une PAC.
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C-Reactive Protein Velocity (CRPv) as a New Biomarker for the Early Detection of Acute Infection/Inflammation. Int J Mol Sci 2022; 23:ijms23158100. [PMID: 35897672 PMCID: PMC9330915 DOI: 10.3390/ijms23158100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 01/08/2023] Open
Abstract
C-reactive protein (CRP) is considered a biomarker of infection/inflammation. It is a commonly used tool for early detection of infection in the emergency room or as a point-of-care test and especially for differentiating between bacterial and viral infections, affecting decisions of admission and initiation of antibiotic treatments. As C-reactive protein is part of a dynamic and continuous inflammatory process, a single CRP measurement, especially at low concentrations, may erroneously lead to a wrong classification of an infection as viral over bacterial and delay appropriate antibiotic treatment. In the present review, we introduce the concept of C-reactive protein dynamics, measuring the velocity of C-reactive protein elevation, as a tool to increase this biomarker’s diagnostic ability. We review the studies that helped define new metrics such as estimated C-reactive protein velocity (velocity of C-reactive protein elevation from symptoms’ onset to first C-reactive protein measurement) and the measured C-reactive protein velocity (velocity between sequential C-reactive protein measurements) and the use of these metrics in different clinical scenarios. We also discuss future research directions for this novel metric.
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