PEDIATRICS Vol. 108 No. 6 December 2001, pp. 1275-1279
C-Reactive Protein in Febrile Children 1 to 36 Months of Age With Clinically Undetectable Serious Bacterial Infection
* Department of Pediatrics, Temple University School of Medicine, Temple University Children’s Medical Center, Philadelphia, Pennsylvania
Department of Pediatrics, Division of Emergency Medicine, Jefferson Medical College, duPont Hospital for Children, Wilmington, Delaware
Objective. To determine the diagnostic properties of quantitative C-reactive protein (CRP) associated with clinically undetectable serious bacterial infection (SBI) in febrile children 1 to 36 months of age.
Methods. Febrile children presenting to a pediatric emergency department (ED) with ages ranging from 1 to 36 months, temperatures 
39°C, and clinically undetectable source of fever were enrolled in this prospective cohort study. Demographic information, ED temperature, duration of fever, and clinical evaluation using the Yale observation scale were recorded at the time of the initial evaluation. The white blood cell count (WBC), band count, absolute neutrophil count (ANC), and CRP concentration were measured at the same time. All patients received blood cultures and either a screening urinalysis or urine culture. A chest radiograph was obtained at the discretion of the ED physician. Patients with history of using antibiotics within 1 week of their presentation to the ED were excluded. The main outcome result was the presence of laboratory or radiographically proven SBI (bacteremia, meningitis, urinary tract infection, pneumonia, septic arthritis, and osteomyelitis).
Results. Seventy-seven patients were enrolled in the study. Fourteen (18%) had a SBI (6 urinary tract infection; 4 pneumonia, including 1 patient with Streptococcus pneumoniae bacteremia; and 4 occult S pneumoniae bacteremia), and 63 had no SBI. The 2 groups were indistinguishable in age, sex, ED temperature, duration of fever, and Yale observation scale. CRP concentration, WBC, and ANC were significantly different between the 2 groups. In a multivariate logistic regression analysis, only CRP remained as a predictor of SBI (Beta = 0.76, 95% confidence interval [CI]: 0.64, 0.89). Receiver-operating characteristic analysis demonstrated CRP (area under curve [AUC] 0.905, standard error [SE] 0.05, 95% CI: 0.808, 1.002) to be superior to ANC (AUC 0.805, SE 0.051, 95% CI: 0.705, 0.905) and to WBC (AUC 0.761, SE 0.068, 95% CI: 0.628, 0.895). A CRP cutoff point of 7 was determined to maximize both sensitivity and specificity (sensitivity 79%, specificity 91%, likelihood ratio 8.3, 95% CI: 3.8, 27.3). Multilevel likelihood ratios and posttest probabilities were calculated for a variety of CRP levels. A CRP concentration of <5 mg/dL effectively ruled out SBI (likelihood ratio 0.087, 95% CI: 0.02, 0.38, posttest probability of SBI 1.9%).
Conclusions. Quantitative CRP concentration is a valuable laboratory test in the evaluation of febrile young children who are at risk for occult bacteremia and SBI, with a better predictive value than the WBC or ANC.
Key Words: C-reactive protein • fever • serious bacterial infection • bacteremia • urinary tract infection
Abbreviations: SBI, serious bacterial infection • OB, occult bacteremia • UTI, urinary tract infection • WBC, white blood cell count • ANC, absolute neutrophil count • CRP, C-reactive protein • ED, emergency department • YOS, Yale Observational Score • ROC, receiver operating characteristic • CI, confidence interval • SD, standard deviation • SE, standard error • PPV, positive predictive value • NPV, negative predictive value
Received for publication Apr 16, 2001; Accepted Jul 7, 2001.
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  W. I. Krief, D. A. Levine, S. L. Platt, C. G. Macias, P. S. Dayan, J. J. Zorc, N. Feffermann, N. Kuppermann, and for the Multicenter RSV-SBI Study Group of the Ped Influenza Virus Infection and the Risk of Serious Bacterial Infections in Young Febrile Infants Pediatrics, July 1, 2009; 124(1): 30 - 39. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 I Olaciregui, U Hernandez, J A Munoz, J I Emparanza, and J J Landa Markers that predict serious bacterial infection in infants under 3 months of age presenting with fever of unknown origin Arch. Dis. Child., July 1, 2009; 94(7): 501 - 505. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. W Attia Review: C-reactive protein has moderate diagnostic accuracy for serious bacterial infection in children with fever Evid. Based Med., April 1, 2009; 14(2): 56 - 56. [Full Text] [PDF]
|
|
|
|
 |
|
 H.-L. Chen, C.-H. Hung, H.-I Tseng, and R.-C. Yang Plasma IP-10 as a Predictor of Serious Bacterial Infection in Infants Less than 4 Months of Age J Trop Pediatr, April 1, 2009; 55(2): 103 - 108. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Q. Tan Procalcitonin in Young Febrile Infants for the Detection of Serious Bacterial Infections: Is This the "Holy Grail"? Pediatrics, November 1, 2008; 122(5): 1117 - 1118. [Full Text] [PDF]
|
|
|
|
|
|
V. Maniaci, A. Dauber, S. Weiss, E. Nylen, K. L. Becker, and R. Bachur Procalcitonin in Young Febrile Infants for the Detection of Serious Bacterial Infections Pediatrics, October 1, 2008; 122(4): 701 - 710. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. L Coles, A. Bose, P. D Moses, L. Mathew, I. Agarwal, T. Mammen, and M. Santosham Infectious etiology modifies the treatment effect of zinc in severe pneumonia Am. J. Clinical Nutrition, August 1, 2007; 86(2): 397 - 403. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Maheshwari How useful is C-reactive protein in detecting occult bacterial infection in young children with fever without apparent focus? Arch. Dis. Child., June 1, 2006; 91(6): 533 - 535. [Full Text] [PDF]
|
|
|
|
|
|
A. L. Hsiao, L. Chen, and M. D. Baker Incidence and Predictors of Serious Bacterial Infections Among 57- to 180-Day-Old Infants Pediatrics, May 1, 2006; 117(5): 1695 - 1701. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. P. Kourtis, D. T. Sullivan, and U. Sathian Practice Guidelines for the Management of Febrile Infants Less Than 90 Days of Age at the Ambulatory Network of a Large Pediatric Health Care System in the United States: Summary of New Evidence Clinical Pediatrics, January 1, 2004; 43(1): 11 - 16. [PDF]
|
|
|
|
|
|
A. Galetto-Lacour, S. A. Zamora, and A. Gervaix Bedside Procalcitonin and C-Reactive Protein Tests in Children With Fever Without Localizing Signs of Infection Seen in a Referral Center Pediatrics, November 1, 2003; 112(5): 1054 - 1060. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Kuppermann The Evaluation of Young Febrile Children for Occult Bacteremia: Time to Reevaluate Our Approach? Arch Pediatr Adolesc Med, September 1, 2002; 156(9): 855 - 857. [Full Text] [PDF]
|
|
|
|
|
|
D. J. Isaacman and B. L. Burke Utility of the Serum C-reactive Protein for Detection of Occult Bacterial Infection in Children Arch Pediatr Adolesc Med, September 1, 2002; 156(9): 905 - 909. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. E. Carroll, M. Silverstein, P. N. Pulliam, M. W. Attia, and K. M. Cronan C-Reactive Protein? Pediatrics, August 1, 2002; 110(2): 422 - 422. [Full Text] [PDF]
|
|
|
|
 |
|
 Is C-Reactive Protein a Good Screening Test for Occult Infection in Febrile Children? Journal Watch Emergency Medicine, January 30, 2002; 2002(130): 8 - 8. [Full Text]
|
|
