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C-reactive protein (CRP) has been shown to be a valuable marker in the diagnosis of infection and in monitoring its response to antibiotics. Our objective was to evaluate serial CRP measurements after prescription of antibiotics to describe the clinical course of Community-Acquired Sepsis admitted to intensive care units (ICU).During a 12-month period a multi-center, prospective, observational study was conducted, segregating adults with Community-Acquired Sepsis. Patients were followed-up during the first five ICU days, day of ICU discharge or death and hospital outcome. CRP-ratio was calculated in relation to Day 1 CRP concentration. Patients were classified according to the pattern of CRP-ratio response to antibiotics: fast response if Day 5 CRP-ratio was0.4, slow response if Day 5 CRP-ratio was between 0.4 and 0.8, and no response if Day 5 CRP-ratio was0.8. Comparison between survivors and non-survivors was performed.A total of 891 patients (age 60 ± 17 yrs, hospital mortality 38%) were studied. There were no significant differences between the CRP of survivors and non-survivors until Day 2 of antibiotic therapy. On the following three days, CRP of survivors was significantly lower (P0.001). After adjusting for the Simplified Acute Physiology Score II and severity of sepsis, the CRP course was significantly associated with mortality (ORCRP-ratio = 1.03, confidence interval 95%= (1.02, 1.04), P0.001). The hospital mortality of patients with fast response, slow response and no response patterns was 23%, 30% and 41%, respectively (P = 0.001). No responders had a significant increase on the odds of death (OR = 2.5, CI95% = (1.6, 4.0), P0.001) when compared with fast responders.Daily CRP measurements after antibiotic prescription were useful as early as Day 3 in identification of Community-Acquired Sepsis patients with poor outcome. The rate of CRP decline during the first five ICU days was markedly associated with prognosis. The identification of the pattern of CRP-ratio response was useful in the recognition of the individual clinical course.

Introduction Diagnostic strategies based on tracheal aspirates in patients with severe nursing home-acquired pneumonia have not previously been evaluated. The objectives of the study were to investigate, in patients with severe nursing home-acquired pneumonia, the diagnostic value of quantitative endotracheal aspirate (QEA) cultures using increasing interpretative cutoff points, as compared with bronchoalveolar lavage (BAL) and protected specimen brush (PSB) quantitative cultures. Methods Seventy-five nursing home patients requiring mechanical ventilation for suspected pneumonia were studied. Endotracheal aspirate, PSB, and BAL samples were obtained consecutively. The diagnostic yield of QEA at thresholds raging from 103 to 107 colony-forming units (cfu)/ml was assessed by calculating sensitivities, specificities, and accuracy rates. A receiver operator characteristic curve for the series of cutoff points was constructed. Results Forty-nine patients were diagnosed with pneumonia either by BAL (≤ 104 cfu/ml) or PSB (≤ 103 cfu/ml). Diagnostic accuracy of QEA was most favorable at 104 cfu/ml. At this threshold, endotracheal aspirates coincided with both BAL and PSB in 30 cases, whereas partial agreement was observed in 14 cases. This resulted in sensitivity and specificity of 90% (95% confidence interval 78% to 97%) and 77% (95% confidence interval 56% to 91%), respectively. QEA findings correlated significantly with both PSB and BAL quantitative cultures (r = 0.71 [P < 0.001] and r = 0.77 [P < 0.001], respectively). Conclusion QEA may be used as a diagnostic tool to determine the presence of pneumonia in ventilated patients admitted from nursing homes when bronchoscopic procedures are not feasible or available.

This study sought to assess the prognostic value of the kinetics of procalcitonin (PCT), C-reactive protein (CRP) and clinical scores (clinical pulmonary infection score (CPIS), Sequential Organ Failure Assessment (SOFA)) in the outcome of ventilator-associated pneumonia (VAP) at an early time point, when adequacy of antimicrobial treatment is evaluated. This prospective observational cohort study was conducted in a teaching hospital. The subjects were 75 patients consecutively admitted to the intensive care unit from October 2003 to August 2005 who developed VAP. Patients were followed for 28 days after the diagnosis, when they were considered survivors. Patients who died before the 28th day were non-survivors. There were no interventions. PCT, CRP and SOFA score were determined on day 0 and day 4. Variables included in the univariable logistic regression model for survival were age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, decreasing ΔSOFA, decreasing ΔPCT and decreasing ΔCRP. Survival was directly related to decreasing ΔPCT with odds ratio (OR) = 5.67 (95% confidence interval 1.78 to 18.03), decreasing ΔCRP with OR = 3.78 (1.24 to 11.50), decreasing ΔSOFA with OR = 3.08 (1.02 to 9.26) and APACHE II score with OR = 0.92 (0.86 to 0.99). In a multivariable logistic regression model for survival, only decreasing ΔPCT with OR = 4.43 (1.08 to 18.18) and decreasing ΔCRP with OR = 7.40 (1.58 to 34.73) remained significant. Decreasing ΔCPIS was not related to survival (p = 0.59). There was a trend to correlate adequacy to survival. Fifty percent of the 20 patients treated with inadequate antibiotics and 65.5% of the 55 patients on adequate antibiotics survived (p = 0.29). Measurement of PCT and CRP at onset and on the fourth day of treatment can predict survival of VAP patients. A decrease in either one of these marker values predicts survival.

Infectious pathologies are among the most prevalent in the ICU and significantly influence the outcome of critically ill patients. However, the emergency of resistant pathogens to different antibiotics makes the choice of the initial treatment more complex. In addition, inadequate empirical antibiotic therapy is associated with a poorer outcome.