C-reactive protein: Difference between revisions

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==Normal Values==
−
= C-reactive protein (CRP) =
  
   
  +
*Post-spinal surgery, it peaks at 15 ± 25 mg/L a few days after OR
−
== Normal Values ==
  
  +
*Post-stroke, it can go up to 25 ± 10 mg/L
  +
*Post-TKA, it can go up to 155 mg/L
   
  +
==Interpretation==
−
* Post-spinal surgery, it peaks at 15 ± 25 a few days after OR
  
−
* Post-stroke, it can go up to 25 ± 10
  
−
* Post-TKA, it can go up to 155 mg/L
  
   
  +
*The higher the value, the more likely to be a bacterial infection
−
== Interpretation ==
  
  +
**Non-infectious chronic inflammation, such as from smoking, uremia, or cardiac ischemia: 2 to 10 mg/L
  +
**Mild to moderate infection such as SSTI, cystitis or bronchitis: increases to 50 to 100 mg/L within 6 hours
  +
*Typically begins to rise after 12 to 24 hours and has a half-life of about 19 hours
   
  +
{| class="wikitable"
−
* The higher the value, the more likely to be a bacterial infection
  
  +
!Condition
  +
!Cutoff
  +
!Sensitivity
  +
!Specificity
  +
!Notes
  +
|-
  +
| rowspan="3" |Diabetic foot [[osteomyelitis]]
  +
|>10
  +
|0.85
  +
|0.59
  +
| rowspan="3" |near-normal by day 7 to 21 of treatment[[CiteRef::michail2013th]]
  +
|-
  +
|>14
  +
|0.84
  +
|0.83
  +
|-
  +
|>17
  +
|0.77
  +
|0.89
  +
|-
  +
|[[Necrotizing soft tissue infections|Necrotizing SSTI]]
  +
|>150
  +
|
  +
|
  +
|included in LRINEC score
  +
|-
  +
|[[Prosthetic joint infection]]
  +
|>10
  +
|0.96
  +
|0.92
  +
|[[CiteRef::spangehl1999pr]]
  +
|-
  +
|[[Spondylodiscitis]]
  +
|
  +
|
  +
|
  +
|normalizes within 3 months of treatment
  +
|-
  +
|[[Septic arthritis]]
  +
|≥20
  +
|0.92
  +
|
  +
|[[CiteRef::hariharan2011se]]
  +
|}
   
  +
===Comparison to ESR===
−
== Further Reading ==
  
  +
{| class="wikitable"
  +
!ESR
  +
!CRP
  +
!Clinical Scenarios
  +
|-
  +
|high
  +
|low
  +
|[[rheumatoid arthritis]], infection, low albumin, elevated creatinine
  +
|-
  +
|low
  +
|high
  +
|low albumin
  +
|}
   
  +
*CRP less effected by older age than ESR
−
=== Spine ===
  
   
  +
=== Hemodialysis ===
−
* [https://doi.org/10.1016/j.spinee.2005.07.006 Serum C-reactive protein levels correlate with clinical response in patients treated with antibiotics for wound infections after spinal surgery]. ''Spine J''. 2006;6(3):311-315.
  
−
** CRP better than ESR
  
   
  +
* Theoretically removed with hemodialysis<ref>Honore, P.M., De Bels, D., Attou, R. ''et al.'' The challenge of removal of sepsis markers by continuous hemofiltration. ''Crit Care'' 23, 173 (2019). https://doi.org/10.1186/s13054-019-2464-z</ref>, but CRP is often elevated in stable patients on hemodialysis and peritoneal dialysis<ref>Borazan A, Aydemir S, Sert M, Yilmaz A. The effects of hemodialysis and peritoneal dialysis on serum homocysteine and C-reactive protein levels. Mediators Inflamm. 2004 Dec;13(5-6):361-4. doi: [https://doi.org/10.1080/09629350400008786 10.1080/09629350400008786]. PMID: 15770053; PMCID: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781575/ PMC1781575].</ref>
−
=== Joints ===
  
   
  +
==Further Reading==
−
* [https://doi.org/10.1093/jac/dkr182 Serial measurement of the C-reactive protein is a poor predictor of treatment outcome in prosthetic joint infection]. ''J Antimicrob Chemo''. 2011;66(7);1590-1593.
  
−
** Although the population of patients with failure had higher CRP on average, CRP measurement was not useful for predicting failure in individual patients.
  
−
* [https://doi.org/10.1371/journal.pone.0009358 C-Reactive Protein, Erythrocyte Sedimentation Rate and Orthopedic Implant Infection]. ''PLoS ONE''. 2010:5(2):e9358.
  
−
** ESR and CRP have poor Sn and Sp for diagnosing hardware infections
  
−
* [https://doi.org/10.1007/s00264-017-3430-5 C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections]. ''International Orthopaedics''. 2017.
  
−
** 1/3 of culture-positive PJIs had normal CRP and 1/4 had normal ESR.
  
−
** Most common associated organisms were coagulase-negative staphylococci and ''C. acnes''
  
−
* [https://doi.org/10.1302/0301-620X.97B7.35500 Seronegative infections in hip and knee arthroplasty: periprosthetic infections with normal erythrocyte sedimentation rate and C-reactive protein level]
  
−
** 4% of PJI have normal CRP and ESR
  
−
** CoNS was more common, ''Staph. aureus'' less common
  
   
  +
* Acute Phase Reactants in Infections: Evidence- Based Review and a Guide for Clinicians. ''Open Forum Infect Dis''. 2015;2(3):ofv098. doi: [https://doi.org/10.1093/ofid/ofv098 10.1093/ofid/ofv098].
−
=== Other ===
  
   
  +
===Spine===
−
* [https://doi.org/10.1001/archinternmed.2007.73 Prognostic Value of Serial C-Reactive Protein Measurements in Left-Sided Native Valve Endocarditis]. ''Arch Intern Med''. 2008;168(3):302-307.
  
  +
−
** After 1 week following starting therapy, a CRP over 122 predicts failure (OR 10)
  
−
* [https://doi.org/10.1016/0003-4975(94)90206-2 Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy]. ''Annals Thoracic Surg''. 1994;57(4):933-936.
 +
*[https://doi.org/10.1016/j.spinee.2005.07.006 Serum C-reactive protein levels correlate with clinical response in patients treated with antibiotics for wound infections after spinal surgery]. ''Spine J''. 2006;6(3):311-315.
  +
**CRP better than ESR
−
** Post-operative rise or high-plateau of CRP predicted postoperative infection (empyema)
  
  +
−
* [https://doi.org/10.1007/s11605-009-0928-1 Diagnostic Accuracy of C-reactive Protein for Intraabdominal Infections After Colorectal Resections]. ''J Gastrointest Surg''. 2009;13(9):1599-1606.
  
  +
===Joints===
−
** Post-resection day 3 (or 5 or 7) CRP predicts intraabdominal infection, with Sn 82% and Sp 73% using a cutoff of 190 mg/L (normal &lt;10)
  
  +
  +
*[https://doi.org/10.1093/jac/dkr182 Serial measurement of the C-reactive protein is a poor predictor of treatment outcome in prosthetic joint infection]. ''J Antimicrob Chemo''. 2011;66(7);1590-1593.
  +
**Although the population of patients with failure had higher CRP on average, CRP measurement was not useful for predicting failure in individual patients.
  +
*[https://doi.org/10.1371/journal.pone.0009358 C-Reactive Protein, Erythrocyte Sedimentation Rate and Orthopedic Implant Infection]. ''PLoS ONE''. 2010:5(2):e9358.
  +
**ESR and CRP have poor Sn and Sp for diagnosing hardware infections
  +
*[https://doi.org/10.1007/s00264-017-3430-5 C-reactive protein may misdiagnose prosthetic joint infections, particularly chronic and low-grade infections]. ''International Orthopaedics''. 2017.
  +
**1/3 of culture-positive PJIs had normal CRP and 1/4 had normal ESR.
  +
**Most common associated organisms were coagulase-negative staphylococci and ''C. acnes''
  +
*[https://doi.org/10.1302/0301-620X.97B7.35500 Seronegative infections in hip and knee arthroplasty: periprosthetic infections with normal erythrocyte sedimentation rate and C-reactive protein level]
  +
**4% of PJI have normal CRP and ESR
  +
**CoNS was more common, ''Staph. aureus'' less common
  +
  +
===Other===
  +
  +
*[https://doi.org/10.1001/archinternmed.2007.73 Prognostic Value of Serial C-Reactive Protein Measurements in Left-Sided Native Valve Endocarditis]. ''Arch Intern Med''. 2008;168(3):302-307.
  +
**After 1 week following starting therapy, a CRP over 122 predicts failure (OR 10)
  +
*[https://doi.org/10.1016/0003-4975(94)90206-2 Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy]. ''Annals Thoracic Surg''. 1994;57(4):933-936.
  +
**Post-operative rise or high-plateau of CRP predicted postoperative infection (empyema)
  +
*[https://doi.org/10.1007/s11605-009-0928-1 Diagnostic Accuracy of C-reactive Protein for Intraabdominal Infections After Colorectal Resections]. ''J Gastrointest Surg''. 2009;13(9):1599-1606.
  +
**Post-resection day 3 (or 5 or 7) CRP predicts intraabdominal infection, with Sn 82% and Sp 73% using a cutoff of 190 mg/L (normal &lt;10)
  +
  +
[[Category:Diagnostics]]

Latest revision as of 15:43, 7 March 2023

Normal Values

  • Post-spinal surgery, it peaks at 15 ± 25 mg/L a few days after OR
  • Post-stroke, it can go up to 25 ± 10 mg/L
  • Post-TKA, it can go up to 155 mg/L

Interpretation

  • The higher the value, the more likely to be a bacterial infection
    • Non-infectious chronic inflammation, such as from smoking, uremia, or cardiac ischemia: 2 to 10 mg/L
    • Mild to moderate infection such as SSTI, cystitis or bronchitis: increases to 50 to 100 mg/L within 6 hours
  • Typically begins to rise after 12 to 24 hours and has a half-life of about 19 hours
Condition Cutoff Sensitivity Specificity Notes
Diabetic foot osteomyelitis >10 0.85 0.59 near-normal by day 7 to 21 of treatment1
>14 0.84 0.83
>17 0.77 0.89
Necrotizing SSTI >150 included in LRINEC score
Prosthetic joint infection >10 0.96 0.92 2
Spondylodiscitis normalizes within 3 months of treatment
Septic arthritis ≥20 0.92 3

Comparison to ESR

ESR CRP Clinical Scenarios
high low rheumatoid arthritis, infection, low albumin, elevated creatinine
low high low albumin
  • CRP less effected by older age than ESR

Hemodialysis

  • Theoretically removed with hemodialysis[1], but CRP is often elevated in stable patients on hemodialysis and peritoneal dialysis[2]

Further Reading

  • Acute Phase Reactants in Infections: Evidence- Based Review and a Guide for Clinicians. Open Forum Infect Dis. 2015;2(3):ofv098. doi: 10.1093/ofid/ofv098.

Spine

Joints

Other

  1. ↑ Honore, P.M., De Bels, D., Attou, R. et al. The challenge of removal of sepsis markers by continuous hemofiltration. Crit Care 23, 173 (2019). https://doi.org/10.1186/s13054-019-2464-z
  2. ↑ Borazan A, Aydemir S, Sert M, Yilmaz A. The effects of hemodialysis and peritoneal dialysis on serum homocysteine and C-reactive protein levels. Mediators Inflamm. 2004 Dec;13(5-6):361-4. doi: 10.1080/09629350400008786. PMID: 15770053; PMCID: PMC1781575.

References

  1. ^  Marios Michail, Edward Jude, Christos Liaskos, Spyridon Karamagiolis, Konstantinos Makrilakis, Dimitrios Dimitroulis, Othon Michail, Nicholas Tentolouris. The Performance of Serum Inflammatory Markers for the Diagnosis and Follow-up of Patients With Osteomyelitis. The International Journal of Lower Extremity Wounds. 2013;12(2):94-99. doi:10.1177/1534734613486152.
  2. ^  MARK J. SPANGEHL, BASSAM A. MASRI, JOHN X. OʼCONNELL, CLIVE P. DUNCAN. Prospective Analysis of Preoperative and Intraoperative Investigations for the Diagnosis of Infection at the Sites of Two Hundred and Two Revision Total Hip Arthroplasties*. The Journal of Bone & Joint Surgery. 1999;81(5):672-83. doi:10.2106/00004623-199905000-00008.
  3. ^  Praveen Hariharan, Christopher Kabrhel. Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients. The Journal of Emergency Medicine. 2011;40(4):428-431. doi:10.1016/j.jemermed.2010.05.029.

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