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Utility of the Serum C-reactive Protein for Detection of Occult Bacterial Infection in Children
Daniel J. Isaacman, MD;
Bonnie L. Burke, MS
Arch Pediatr Adolesc Med. 2002;156:905-909.
Objective To assess the utility of serum C-reactive protein (CRP) as a screen
for occult bacterial infection in children.
Methods Febrile children ages 3 to 36 months who visited an urban children's
hospital emergency department and received a complete blood cell count and
blood culture as part of their evaluation were prospectively enrolled from
February 2, 2000, through May 30, 2001. Informed consent was obtained for
the withdrawal of an additional 1-mL aliquot of blood for use in CRP evaluation.
Logistic regression and receiver operator characteristic (ROC) curves were
modeled for each predictor to identify optimal test values, and were compared
using likelihood ratio tests.
Results Two hundred fifty-six patients were included in the analysis, with a
median age of 15.3 months (range, 3.1-35.2 months) and median temperature
at triage 40.0°C (range, 39.0°C-41.3°C). Twenty-nine (11.3%) cases
of occult bacterial infection (OBI) were identified, including 17 cases of
pneumonia, 9 cases of urinary tract infection, and 3 cases of bacteremia.
The median white blood cell count in this data set was 12.9 x 109/µL (range, 3.6-39.1 x109/µL), the median
absolute neutrophil count (ANC) was 7.12 x 109/L (range,
0.56-28.16 x109/L), and the median CRP level was 1.7 mg/dL
(range, 0.2-43.3 mg/dL). The optimal cut-off point for CRP in this data set
(4.4 mg/dL) achieved a sensitivity of 63% and a specificity of 81% for detection
of OBI in this population. Comparing models using cut-off values from individual
laboratory predictors (ANC, white blood cell count, and CRP) that maximized
sensitivity and specificity revealed that a model using an ANC of 10.6 x109/L (sensitivity, 69%; specificity, 79%) was the best predictive model.
Adding CRP to the model insignificantly increased sensitivity to 79%, while
significantly decreasing specificity to 50%. Active monitoring of emergency
department blood cultures drawn during the study period from children between
3 and 36 months of age showed an overall bacteremia rate of 1.1% during this
period.
Conclusions An ANC cut-off point of 10.6 x109/L offers the best
predictive model for detection of occult bacterial infection using a single
test. The addition of CRP to ANC adds little diagnostic utility. Furthermore,
the lowered incidence of occult bacteremia in our population supports a decrease
in the use of diagnostic screening in this population.
From the Department of Pediatrics, Eastern Virginia Medical School,
Children's Hospital of The King's Daughters, Norfolk, Va.
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