Edip ÜNAL, Mehmet Atilla TÜRKMEN, Mehmet Ali ÖKTEM, Ayhan ABACI

Utility of the serum C- reactive protein and procalcitonin for detection of occult bacterial infection in 3-36 month old children

Amaç: Üç–36 ay arası gizli bakteriyel enfeksiyon riski taşıyan hastaların saptanmasında C-reaktif proteinin (CRP) ve Prokalsitoninin (PCT) kullanılabilirliğini saptamak. Gereç ve Yöntem: Yaşları 3-36 ay arası olan, 38.3oC üzerinde ateş yüksekliği şikayeti ile acil servise başvuran ve ateş odağı saptanamayan hastalar çalışmaya alındı. Başvuru anında, cinsiyetleri, yaşları, ateş yüksekliğinin derecesi, Yale Gözlem Ölçeği (YGÖ) skoru, hastaneye yatma ve antibiyotik başlanma durumları kaydedildi. Başvuru anında, rutin idrar analizi, beyaz küre sayıları, CRP ve PCT’nin düzeylerinin ölçümü için testler yapıldı. Viral serolojik inceleme yapıldı ve akut faz dönemindeki spesifik IgM pozitifliği ve/veya konvalasan fazda spesifik IgG düzeylerinde 4 katlık artış pozitif olarak kabul edildi. Tüm hastalardan kan kültürü, idrar kültürü yapıldı ve akciğer grafileri çekildi. Hastalar gizli bakteriyal enfeksiyon ve viral enfeksiyon grubu olmak üzere ikiye ayrıldı. İki grup verileri her bir belirleyici açısından karşılaştırıldı. Bulgular: Gizli bakteriyel enfeksiyonlu 10 hastada, altı idrar yolu enfeksiyonu, iki bronkopnömoni, bir menenjit, bir bakteriyemili hasta saptanırken, viral enfeksiyon saptanan 16 hastada, beş Adenovirus, beş Respiratory syncytial virus, dört Enterovirus, bir Parainfluenza Tip1 ve bir Epstein-Barr virus enfeksiyonlu hasta saptandı. Gizli bakteriyel enfeksiyon grubu, viral enfeksiyon grubu ile CRP değerleri açısından karşılaştırıldığında istatistiksel olarak anlamlı fark saptanmazken (sırasıyla, ortanca 44.84 mg/L ve 23.3 mg/L, p=0.097), PCT değerleri istatistiksel olarak anlamlı saptandı (sırasıyla, ortanca 2.38 ng/mL, 0.28 ng/mL, p=0.014). Sonuç: Bu çalışma, çocuk acil bölümlerinde PCT’nin gizli bakteriyel enfeksiyonları saptamada CRP’ye göre daha üstün bir belirleyici olduğunu ve tarama amaçlı kullanılabileceğini, ancak bazı viral enfeksiyonlarda yüksek saptanabileceğini göstermiştir.

Üç-36 ay arası çocuklarda gizli bakteriyel enfeksiyonları saptamada C-reaktif proteinin ve prokalsitoninin kullanııabilirliği

Aim: To assess the utility of serum C-reactive protein (CRP) and Procalcitonin (PCT) as a screening method for occult bacterial infection (OBI) in 3-36 month old children. Materials and Methods: Febrile children, who were admitted to emergency department with ages ranging from 3 to 36 months, temperatures > 38.3°C, and clinically undetectable source of fever, were enrolled in this study. Sex, age, degree of fever, Yale Observation Scale (YOS) score, antibiotic treatment and hospitalization were recorded at the time of the initial evaluation. Routine urine analysis, white blood cell count (WBC) count, CRP and PCT determination tests were performed at the initial evaluation. Viral serology was done and patients having specific IgM positivity during the acute phase and/or a four-fold increase in specific IgG titer during convalescence phase were considered to be positive. A chest radiograph, blood culture and urine cultures were taken from all patients. The patients were divided into two groups: OBI group and viral infection group. These two groups were compared for each predictor. Results: There were 10 patients with OBI, six with urinary tract infection two with pneumonia, one with bacterial meningitis and one with bacteremia and 16 patients with viral infection, (five Adenovirus, five Respiratory syncytial virus, four Enterovirus, one Parainfluenza type 1, one Epstein- Barr virus. Regarding the CRP values, there was no statistical difference between OBI and viral infection groups (respectively, median 44.84 mg/L and 23.3 mg/L, p=0.097), but PCT values were significantly higher in OBI group (respectively, median 2.38 ng/mL and 0.28 ng/mL, p=0.014). Conclusion: This study showed that PCT is superior than CRP in detecting OBI and could be used for screening purposes in pediatric emergency departments while elevated levels might be found in some viral infections.

PDF

___

1. Pulliam PN, Attia MW, Cronan KM. Creactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics 2001;108:1275-1279.
2. Kuppermann N. Occult bacteremia in young febrile children. Pediatr Clin North Am 1999;46:1073-1109.
3. Isaacman DJ, Burke BL. Utility of the serum C-reactive protein for detection of occult bacterial infection in children. Arch Pediatr Adolesc Med 2002;156:905-909.
4. Finkelstein JA, Christiansen CL, Platt R. Fever in pediatric primary care: occurrence, management, and outcomes. Pediatrics 2000;105:260-266.
5. Braithwaite S. Procalcitonin: new insights on regulation and origin. Crit Care Med 2000;28:586-588.
6. Hatherill M, Tibby SM, Sykes K,et al. Diagnostic markers of infection: comparison of procalcitonin with C reactive protein and leucocyte count. Arch Dis Child 1999;81:417-421.
7. Lacour AG, Gervaix A, Zamora SA, et al. Procalcitonin, IL-6, IL-8, IL-1 receptor antagonist and C-reactive protein as identificators of serious bacterial infections in children with fever without localising signs. Eur J Pediatr 2001;160:95-100.
8. Nijsten MW, Olinga P, The TH, et al. Procalcitonin behaves as a fast responding acute phase protein in vivo and in vitro. Crit Care Med 2000;28:458-461.
9. Schwarz S, Bertram M, Schwab S, et al. Serum procalcitonin levels in bacterial and abacterial meningitis. Crit Care Med 2000;28:1828-1832.
10. Smolkin V, Koren A, Raz R, et al. Procalcitonin as a marker of acute pyelonephritis in infants and children. Pediatr Nephrol 2002;17:409-412.
11. Thayyil S, Shenoy M, Hamaluba M, et al. Is procalcitonin useful in early diagnosis of serious bacterial infections in children? Acta Paediatr 2005;94:155-158.
12. Vincent JL. Procalcitonin: THE marker of sepsis? Crit Care Med 2000;28:1226-1228.
13. Whicher J, Bienvenu J, Monneret G. Procalcitonin as an acute phase marker. Ann Clin Biochem 2001;38:483-493.
14. Rush S.S. Procalcitonin--Marker or mediator? Crit Care Med 1998;26:977-978.
15. Jaye DL, Waites KB. Clinical applications of C-reactive protein in pediatrics. Pediatr Infect Dis J 1997;16:735-746.
16. Fernandez LA, Luaces CC, Garcia JJ, et al. Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker. Pediatr Infect Dis J 2003;22:895-903.
17. Gendrel D, Raymond J, Coste J, et al. Comparison of procalcitonin with C-reactive protein, interleukin 6 and interferon-alpha for differentiation of bacterial vs. viral infections. Pediatr Infect Dis J 1999;18:875-881.
18. McCarthy PL, Sharpe MR, Spiesel SZ, et al. Observation scales to identify serious illness in febrile children. Pe diatrics 1982;70:802-809.
19. Alper BS, Curry SH. Urinary tract infection in children. Am Fam Physician 2005;72:2483-2488.
20. Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med 2000;36:602-614.
21. Kuppermann N, Fleisher GR, Jaffe DM. Predictors of occult pneumococcal bacteremia in young febrile children. Ann Emerg Med 1998;31:679-687.
22. Hsiao AL, Baker MD. Fever in the new millennium: a review of recent studies of markers of serious bacterial infection in febrile children. Curr Opin Pediatr 2005;17:56-61.
23. Baraff LJ, Bass JW, Fleisher GR,et al. Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research. Ann Emerg Med 1993;22:1198-1210.
24. Pratt A, Attia MW. Duration of fever and markers of serious bacterial infection in young febrile children. Pediatr Int 2007;49:31-35.
25. van Rossum AM, Wulkan RW, Oudesluys- Murphy AM. Procalcitonin as an early marker of infection in neonates and children. Lancet Infect Dis 2004;4:620-630.
26. Peltola H, Jaakkola M. C-reactive protein in early detection of bacteremic versus viral infections in immunocompetent and compromised children. J Pediatr 1988;113:641- 646.
27. Simon L, Gauvin F, Amre DK, et al. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis. Clin Infect Dis 2004;39:206-217.
28. Assicot M, Gendrel D, Carsin H, et al. High serum procalcitonin concentrations in patients with sepsis and infection. Lancet 1993;341:515-518.
29. Muller B, Becker KL. Procalcitonin: how a hormone became a marker and mediator of sepsis. Swiss Med Wkly 2001;131:595-602.
30. Whang KT, Steinwald PM, White JC, et al. Serum calcitonin precursors in sepsis and systemic inflammation. J Clin Endocrinol Metab 1998;83:3296-3301.
31. Galetto-Lacour A, Zamora SA, Gervaix A. Bedside procalcitonin and C-reactive protein tests in children with fever without localizing signs of infection seen in a referral center. Pediatrics 2003;112:1054-1060.
32. Turner RB, Lande AE, Chase P, et al. Pneumonia in pediatric outpatients: cause and clinical manifestations. J Pediatr 1987;111:194-200.
33. Bettenay FA, de Campo JF, McCrossin DB. Differentiating bacterial from viral pneumonias in children. Pediatr Radiol 1988;18:453-454.
34. Toikka P, Irjala K, Juven T, et al. Serum procalcitonin, C-reactive protein and interleukin-6 for distinguishing bacterial and viral pneumonia in children. Pediatr Infect Dis J 2000;19:598-602.
35. Appenzeller C, Ammann RA, Duppenthaler A, et al. Serum C-reactive protein in children with adenovirus infection. Swiss Med Wkly 2002;132:345-350.
36. Kawasaki Y, Hosoya M, Katayose M, et al. Correlation between serum interleukin 6 and C-reactive protein concentrations in patients with adenoviral respiratory infection. Pediatr Infect Dis J 2002;21:370-374.
37. Ruuskanen O, Putto A, Sarkkinen H, et al. C-reactive protein in respiratory virus infections. J Pediatr 1985;107:97-100.
38. Chua AP, Lee KH. Procalcitonin in severe acute respiratory syndrome (SARS). J Infect 2004;48:303-306.