Advertisement

C-reactive protein (CRP) measurement in geriatric patients hospitalized for acute infection

  • Andrea Ticinesi
    Correspondence
    Corresponding author at: Department of Clinical and Experimental Medicine, University of Parma and Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy.
    Affiliations
    Department of Clinical and Experimental Medicine, University of Parma, Italy

    Internal Medicine and Critical Subacute Care Unit, Medicine Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
  • Fulvio Lauretani
    Affiliations
    Department of Clinical and Experimental Medicine, University of Parma, Italy

    Internal Medicine and Critical Subacute Care Unit, Medicine Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
  • Antonio Nouvenne
    Affiliations
    Department of Clinical and Experimental Medicine, University of Parma, Italy

    Internal Medicine and Critical Subacute Care Unit, Medicine Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
  • Emanuela Porro
    Affiliations
    Internal Medicine and Critical Subacute Care Unit, Medicine Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
  • Guido Fanelli
    Affiliations
    Department of Surgical Sciences, University of Parma, Italy

    Anesthesia, Intensive Care and Pain Therapy Unit, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
  • Marcello Maggio
    Affiliations
    Department of Clinical and Experimental Medicine, University of Parma, Italy

    Clinical Geriatrics Unit, Medicine Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
  • Tiziana Meschi
    Affiliations
    Department of Clinical and Experimental Medicine, University of Parma, Italy

    Internal Medicine and Critical Subacute Care Unit, Medicine Geriatric-Rehabilitation Department, Azienda Ospedaliero-Universitaria di Parma, Italy
    Search for articles by this author
Published:September 01, 2016DOI:https://doi.org/10.1016/j.ejim.2016.08.026

      Highlights

      • Age-related immunologic rearrangements can affect markers of acute inflammation.
      • Serum CRP elevation can help diagnosing acute infection in older hospitalized patients.
      • CRP measurement may provide prognostic information in older inpatients.
      • The significance of CRP kinetics in older patients with infection is poorly known.

      Abstract

      The physiology of inflammatory response is modified by the aging process and is substantially affected by multimorbidity and disability. Infection is the most frequent cause of acute inflammation in both adult and older subjects. C-reactive protein (CRP) is the most used biomarker of inflammation, and a substantial amount of literature has demonstrated its importance and clinical usefulness in adult subjects. However, the clinical significance of serum CRP determination has not been completely clarified in older subjects with acute infection, especially in the light of the age-related rearrangements in immunity and cytokine production. Thus, in the present review, we focus on the existing knowledge about serum CRP level interpretation in geriatric patients hospitalized with acute infection. Our aims were to determine the significance of CRP measurement at hospital admission for establishing a diagnosis of infection and/or a prognosis and to evaluate whether it is indicated to repeat hs-CRP measurements during hospital stay for monitoring disease course and, possibly, guiding the discharge timing. We concluded that CRP dosage at hospital admission is helpful to detect acute infection, and particularly sepsis, in geriatric patients, and that CRP elevation may provide valuable short-term prognostic information. At the current state of art, serial CRP measurements are instead not indicated to monitor disease course and plan hospital discharge in this setting.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Pepys M.B.
        • Hirschfeld G.M.
        C-reactive protein: a critical update.
        J Clin Invest. 2003; 111: 1805-1812
        • Bertsch T.
        • Triebel J.
        • Bollheimer C.
        • et al.
        C-reactive protein and the acute phase reaction in geriatric patients.
        Z Gerontol Geriatr. 2015; 48: 595-600
        • Povoa P.
        • Salluh J.I.
        Biomarker-guided antibiotic therapy in adult critically ill patients: a critical review.
        Ann Intensive Care. 2012; 2: 32
        • Bogaty P.
        • Dagenais G.R.
        • Joseph L.
        • et al.
        Time variability of C-reactive protein: implications for clinical risk stratification.
        PLoS One. 2013; 8e60759
        • Musunuru K.
        • Kral B.G.
        • Blumenthal R.S.
        • et al.
        The use of high-sensitivity assays for C-reactive protein in clinical practice.
        Nat Clin Pract Cardiovasc Med. 2008; 5: 621-635
        • Cankurtaran M.
        • Ulger Z.
        • Halil M.
        • et al.
        How to assess high erythrocyte sedimentation rate (ESR) in the elderly?.
        Arch Gerontol Geriatr. 2010; 50: 323-326
        • Maggio M.
        • Guralnik J.M.
        • Longo D.L.
        • Ferrucci L.
        Interleukin-6 in aging and chronic disease: a magnificent pathway.
        J Gerontol A Biol Sci Med Sci. 2006; 61: 575-584
        • Bruisman L.R.
        • Luime J.J.
        • Oppe M.
        • Hazes J.M.
        • Rutten-van Mölken M.P.
        A five-year model to assess the early cost-effectiveness of new diagnostic tests in the early diagnosis of rheumatoid arthritis.
        Arthritis Res Ther. 2016; 18: 135
        • Lelubre C.
        • Anselin S.
        • Boudjeltia K.Z.
        • Biston P.
        • Piagnerelli M.
        Interpretation of C-reactive protein concentrations in critically ill patients.
        Biomed Res Int. 2013; ID124021
        • Franceschi C.
        • Campisi J.
        Chronic inflammation (inflammaging) and its potential contribution to age-associated diseases.
        J Gerontol A Biol Sci Med Sci. 2014; 69: S4-S9
        • Opal S.M.
        • Girard T.D.
        • Ely E.W.
        The immunopathogenesis of sepsis in elderly patients.
        Clin Infect Dis. 2005; 41: S504-S512
        • Gomez C.R.
        • Nomellini V.
        • Faunce D.E.
        • Kovacs E.J.
        Innate immunity and aging.
        Exp Gerontol. 2008; 43: 718-728
        • Fabbri E.
        • An Y.
        • Zoli M.
        • et al.
        Aging and burden of multimorbidity: associations with inflammatory and anabolic hormonal biomarkers.
        J Gerontol A Biol Sci Med Sci. 2015; 70: 63-70
        • Cesari M.
        • Penninx B.W.J.H.
        • Pahor M.
        • et al.
        Inflammatory markers and physical performance in older persons: the InCHIANTI study.
        J Gerontol A Biol Sci Med Sci. 2004; 59A: 242-248
        • Walston J.
        • McBurnie M.A.
        • Newman A.
        • et al.
        Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities.
        Arch Intern Med. 2002; 162: 2333-2341
        • Singler K.
        • Bertsch T.
        • Heppner H.J.
        • et al.
        Diagnostic accuracy of three different methods of temperature measurement in acutely ill geriatric patients.
        Age Ageing. 2013; 42: 740-746
        • Faverio P.
        • Aliberti S.
        • Bellelli G.
        • et al.
        The management of community-acquired pneumonia in the elderly.
        Eur J Intern Med. 2014; 25: 312-319
        • Ticinesi A.
        • Nouvenne A.
        • Folesani G.
        • et al.
        An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital.
        Eur J Intern Med. 2016; 28: 102-106
        • Lippi G.
        • Meschi T.
        • Cervellin G.
        Inflammatory biomarkers for the diagnosis, monitoring and follow-up of community-acquired pneumonia: clinical evidence and perspectives.
        Eur J Intern Med. 2011; 22: 460-465
        • Bafadhel M.
        • Clark T.W.
        • Reid C.
        • et al.
        Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD.
        Chest. 2011; 139: 1410-1418
        • Kenny R.A.
        • Hodkinson H.M.
        • Cox M.L.
        • Caspi D.
        • Pepys M.B.
        Acute phase protein response to infection in elderly patients.
        Age Ageing. 1984; 13: 89-94
        • Cox M.L.
        • Rudd A.G.
        • Gallimore R.
        • Hodkinson H.M.
        • Pepys M.B.
        Real-time measurement of serum C-reactive protein in the management of infection in the elderly.
        Age Ageing. 1986; 15: 257-266
        • Stucker F.
        • Herrmann F.
        • Graf J.D.
        • Michel J.P.
        • Krause K.H.
        • Gavazzi G.
        Procalcitonin and infection in elderly patients.
        J Am Geriatr Soc. 2005; 53: 1392-1395
        • Levy M.M.
        • Fink M.P.
        • Marshall J.P.
        • et al.
        2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference.
        Crit Care Med. 2003; 31: 1250-1256
        • Simon L.
        • Gauvin F.
        • Amre D.K.
        • Saint-Louis P.
        • Lacroix J.
        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
        • Aliberti S.
        • Giuliani F.
        • Ramirez J.
        • Blasi F.
        • DURATION Study Group
        How to choose the duration of antibiotic therapy in patients with pneumonia.
        Curr Opin Infect Dis. 2015; 28: 177-184
        • de Jong E.
        • van Oers J.A.
        • Beishuizen A.
        • et al.
        Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomized, controlled, open-label trial.
        Lancet Infect Dis. 2016; 16: 819-827
        • Liu A.
        • Bui T.
        • Van Nguyen H.
        • Ong N.
        • Shen Q.
        • Kamalasena D.
        Serum C-reactive protein as a biomarker for early detection of bacterial infection in the older patient.
        Age Ageing. 2010; 39: 559-565
        • Wester A.L.
        • Blaasaas K.G.
        • Wyller T.B.
        Is the concentration of C-reactive protein in bacteremia associated with age?.
        Immun Ageing. 2008; 5: 8
        • Talebi-Taher M.
        • Babazadeh S.
        • Barati M.
        • Latifnia M.
        Serum inflammatory markers in the elderly: are they useful in differentiating sepsis from SIRS?.
        Acta Med Iran. 2014; 52: 438-442
        • Yilmaz H.
        • Duran L.
        • Yanik K.
        • Altuntas M.
        • Sunbul M.
        Differences in the effectiveness of serum biomarkers for the diagnosis of bacterial infections in adult and elderly patients admitted to the emergency department.
        Turk J Med Sci. 2015; 45: 553-557
        • Esayag Y.
        • Nikitin I.
        • Bar-Ziv J.
        • et al.
        Diagnostic value of chest radiographs in bedridden patients suspected of having pneumonia.
        Am J Med. 2010; 123: 88.e1-88.e5
        • Ticinesi A.
        • Lauretani F.
        • Nouvenne A.
        • et al.
        Lung ultrasound and chest X-ray for detecting pneumonia in an acute geriatric ward.
        Medicine. 2016; 95e4153
        • Nouvenne A.
        • Ticinesi A.
        • Folesani G.
        • et al.
        The association of serum procalcitonin and high-sensitivity C-reactive protein with pneumonia in elderly multimorbid patients with respiratory symptoms: retrospective cohort study.
        BMC Geriatr. 2016; 16: 16
        • van Vugt S.F.
        • Broekhuizen B.D.
        • Lammens C.
        • et al.
        Use of serum C-reactive protein and procalcitonin concentrations in additions to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study.
        BMJ. 2013; 346: f2450
        • Porfyridis I.
        • Georgiadis G.
        • Vogazianos P.
        • Mitis G.
        • Georgiou A.
        C-reactive protein, procalcitonin, clinical pulmonary infection score, and pneumonia severity scores in nursing home acquired pneumonia.
        Respir Care. 2014; 59: 574-581
        • Steichen O.
        • Bouvard E.
        • Grateau G.
        • Bailleul S.
        • Capeau J.
        • Lefèvre G.
        Diagnostic value of procalcitonin in acutely hospitalized elderly patients.
        Eur J Clin Microbiol Infect Dis. 2009; 28: 1471-1476
        • van den Starre W.E.
        • Zunder S.M.
        • Vollaard A.M.
        • et al.
        Prognostic value of pro-adrenomedullin, procalcitonin and C-reactive protein in predicting outcome of febrile urinary tract infection.
        Clin Microbiol Infect. 2014; 20: 1048-1054
        • Ryu J.A.
        • Yang J.H.
        • Lee D.
        • et al.
        Clinical usefulness of procalcitonin and C-reactive protein as outcome predictors in critically ill patients with severe sepsis and septic shock.
        PLoS One. 2015; 10e0138150
        • Viasus D.
        • Del Rio-Pertuz G.
        • Simonetti A.F.
        • et al.
        Biomarkers for predicting short-term mortality in community-acquired pneumonia: a systematic review and meta-analysis.
        J Infect. 2016; 72: 273-282
        • Hohenthal U.
        • Hurme S.
        • Helenius H.
        • et al.
        Utility of C-reactive protein in assessing the disease severity and complications of community-acquired pneumonia.
        Clin Microbiol Infect. 2009; 15: 1026-1032
        • Chalmers J.D.
        • Singanayagam A.
        • Hill A.T.
        C-reactive protein is an independent predictor of severity in community-acquired pneumonia.
        Am J Med. 2008; 121: 219-225
        • Arinzon Z.
        • Peisakh A.
        • Schrire A.
        • Berner Y.
        C-reactive protein (CRP): an important diagnostic and prognostic tool in nursing-home-associated pneumonia.
        Arch Gerontol Geriatr. 2011; 53: 364-369
        • Burlaud A.
        • Mathieu D.
        • Falissard B.
        • Trivalle C.
        Mortality and bloodstream infections in geriatric units.
        Arch Gerontol Geriatr. 2010; 51: e106-e109
        • Ritchie C.W.
        • Newman T.H.
        • Leurent B.
        • Sampson E.L.
        The association between C-reactive protein and delirium in acute elderly hospital admissions.
        Int Psychogeriatr. 2014; 26: 717-724
        • Hogarth M.B.
        • Gallimore J.R.
        • Savage P.
        • et al.
        Acute phase proteins, C-reactive protein and serum amyloid A protein, as prognostic markers in the elderly inpatient.
        Age Ageing. 1997; 26: 153-158
        • Brown S.H.
        • Flint K.
        • Storey A.
        • Abdelhafiz A.H.
        Routinely assessed biochemical markers tested on admission as predictors of adverse outcomes in hospitalized elderly patients.
        Hosp Pract. 1995; 40: 193-201
        • Nouvenne A.
        • Ticinesi A.
        • Lauretani F.
        • et al.
        The prognostic value of high-sensitivity C-reactive protein and prealbumin for short-term mortality in acutely hospitalized multimorbid elderly patients: a prospective cohort study.
        J Nutr Health Aging. 2016; 20: 462-468
        • de Gelder J.
        • Lucke J.A.
        • Heim N.
        • et al.
        Predicting mortality in acutely hospitalized older patients: a retrospective cohort study.
        Intern Emerg Med. 2016; 11: 587-594
        • Comba M.
        • Fonte G.
        • Isaia G.
        • et al.
        Cardiac and inflammatory biomarkers and in-hospital mortality in older medical patients.
        J Am Med Dir Assoc. 2014; 15: 68-72
        • Alrawi Y.A.
        • Parker R.A.
        • Harvey R.C.
        • et al.
        Predictors of early mortality among hospitalized nursing home residents.
        Q J Med. 2013; 106: 51-57
        • Dennis R.A.
        • Johnson L.E.
        • Roberson P.K.
        • et al.
        Changes in activities of daily living, nutrient intake, and systemic inflammation in elderly adults receiving recuperative care.
        J Am Geriatr Soc. 2012; 60: 2246-2253
        • Oliveira C.F.
        • Botoni F.A.
        • Oliveira C.R.A.
        • et al.
        Procalcitonin versus C-reactive protein for guiding antibiotic therapy in sepsis: a randomized trial.
        Crit Care Med. 2013; 41: 2336-2343
        • Lobo S.M.
        • Lobo F.R.
        • Bota D.P.
        • et al.
        C-reactive protein levels correlate with mortality and organ failure in critically ill patients.
        Chest. 2003; 123: 2043-2049
        • Povoa P.
        • Teixeira-Pinto A.M.
        • Carneiro A.H.
        • Portuguese Cummunity-Acquired Sepsis Study Group SACiUCI
        C-reactive protein, an early marker of community-acquired sepsis resolution: a multi-center prospective observational study.
        Crit Care. 2011; 15: R169
        • Moreno M.S.
        • Nietmann H.
        • Matias C.M.
        • et al.
        C-reactive protein: a tool in the follow-up of nosocomial pneumonia.
        J Infect. 2010; 61: 205-211
        • Bruns A.H.W.
        • Oosterheert J.J.
        • Hoepelman A.I.M.
        Usefulness of consecutive C-reactive protein measurements in follow-up of severe community-acquired pneumonia.
        Eur Respir J. 2008; 32: 726-732
        • Menendez R.
        • Martinez R.
        • Reyes S.
        • et al.
        Stability in community-acquired pneumonia: one step forward with markers?.
        Thorax. 2009; 64: 987-992
        • Ruiz-Gonzalez A.
        • Falguera M.
        • Porcel J.M.
        • et al.
        C-reactive protein for discriminating treatment failure from slow responding pneumonia.
        Eur J Intern Med. 2010; 21: 548-552
        • Pinato D.J.
        • Bains J.
        • Irkulla S.
        • et al.
        Advanced age influences the dynamic changes in circulating C-reactive protein following injury.
        J Clin Pathol. 2013; 66: 695-699
        • Beloosesky Y.
        • Hendel D.
        • Weiss A.
        • et al.
        Cytokines and C-reactive protein production in hip-fracture-operated elderly patients.
        J Gerontol A Biol Sci Med Sci. 2007; 62A: 420-426
        • Joffe E.
        • Justo D.
        • Mashav N.
        • et al.
        C-reactive protein to distinguish pneumonia from acute decompensated heart failure.
        Clin Biochem. 2009; 42: 1628-1634
        • Gülcher S.S.
        • Bruins N.A.
        • Kingma W.P.
        • Boerma E.C.
        Elevated C-reactive protein levels at ICU discharge as predictor of ICU outcome: a retrospective cohort study.
        Ann Intensive Care. 2016; 6: 5
        • Ho K.M.
        • Dobb G.J.
        • Lee K.Y.
        • et al.
        C-reactive protein concentration as a predictor of intensive care unit readmission: a nested case–control study.
        J Crit Care. 2006; 21: 259-266
        • Ho K.M.
        • Lee K.Y.
        • Dobb G.J.
        • Towler S.C.
        • Webb S.A.
        C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge: a prospective cohort study.
        Intensive Care Med. 2008; 34: 481-487
        • Ranzani O.T.
        • Prada L.F.
        • Zampieri G.F.
        • et al.
        Failure to reduce C-reactive protein levels more than 25% in the last 24 hours before intensive care unit discharge predicts higher in-hospital mortality: a cohort study.
        J Crit Care. 2012; 27: 525.e9-525.e15
        • Al-Subaie N.
        • Reynolds T.
        • Myers A.
        • et al.
        C-reactive protein as a predictor of outcome after discharge from the intensive care: a prospective observational study.
        Br J Anaesth. 2010; 105: 318-325
        • Chang C.
        • Zhu H.
        • Shen N.
        • Han X.
        • Chen Y.
        • He B.
        Utility of the combination of serum highly-sensitive C-reactive protein level at discharge and a risk index in predicting readmission for acute exacerbation of COPD.
        J Bras Pneumol. 2014; 40: 495-503
        • Alonso-Martinez J.L.
        • Llorente-Diez B.
        • Echegaray-Agara M.
        • Olaz-Preciado F.
        • Urbieta-Echezarreta M.
        • Gonzalez-Arencibia C.
        C-reactive protein as a predictor of improvement and readmission in heart failure.
        Eur J Heart Fail. 2002; 4: 331-336
        • Kalogeropoulos A.P.
        • Tang W.H.W.
        • Hsu A.
        • et al.
        High-sensitivity C-reactive protein in acute heart failure: insights from the ASCEND-HF trial.
        J Card Fail. 2014; 20: 319-326
        • Koppensteiner W.
        • Auersperg V.
        • Halwachs-Baumann G.
        The use of inflammatory markers as a method for discharging patients post hip or knee arthroplasty.
        Clin Chem Lab Med. 2011; 49: 1647-1651