Diagnostic value of C reactive protein in infections of the lower respiratory tract: systematic review

Abstract Objectives To evaluate the diagnostic accuracy of C reactive protein in detecting radiologically proved pneumonia and to evaluate how well it can discriminate between bacterial and viral infections of the lower respiratory tract. Data sources Medline and Embase (January 1966 to April 2004), with reference checking. Study selection We included articles comparing C reactive protein with a chest radiograph or with microbiological work-up as a reference test. Two authors independently assessed methodological items. Results None of the studies met all validity criteria. Six studies used an infiltrate on chest radiograph as reference test. Sensitivities ranged from 10% to 98%, specificities from 44% to 99%. For adults, the relation of C reactive protein with an infiltrate (in a subgroup analysis of five studies) showed an area under the curve of 0.80 (95% confidence interval 0.75 to 0.85). In 12 studies, the relation of C reactive protein with a bacterial aetiology of infection of the lower respiratory tract was studied. Sensitivities ranged from 8% to 99%, specificities from 27% to 95%. These data were epidemiologically and statistically heterogeneous, so overall outcomes could not be calculated. Conclusion Testing for C reactive protein is neither sufficiently sensitive to rule out nor sufficiently specific to rule in an infiltrate on chest radiograph and bacterial aetiology of lower respiratory tract infection. The methodological quality of the diagnostic studies is generally poor. The evidence not consistently and sufficiently supports a wide introduction of C reactive protein as a rapid test to guide antibiotics prescription.

[1]  Irving Kushner,et al.  C-reactive Protein* , 2004, Journal of Biological Chemistry.

[2]  R. Hopstaken,et al.  Inter-observer variation in the interpretation of chest radiographs for pneumonia in community-acquired lower respiratory tract infections. , 2004, Clinical radiology.

[3]  J. Maselli,et al.  Performance of a bedside C-reactive protein test in the diagnosis of community-acquired pneumonia in adults with acute cough. , 2004, The American journal of medicine.

[4]  G. Pera,et al.  Contribution of C-reactive protein to the diagnosis and assessment of severity of community-acquired pneumonia. , 2004, Chest.

[5]  W. Assendelft,et al.  Accuracy of carbohydrate-deficient transferrin in the detection of excessive alcohol consumption: a systematic review. , 2004, Alcohol and alcoholism.

[6]  S. le Cessie,et al.  Pathogens involved in lower respiratory tract infections in general practice. , 2004, The British journal of general practice : the journal of the Royal College of General Practitioners.

[7]  C. Rodrigo,et al.  Procalcitonin, C-reactive protein and leukocyte count in children with lower respiratory tract infection , 2003, The Pediatric infectious disease journal.

[8]  H. Requejo,et al.  C-reactive protein in the diagnosis of community-acquired pneumonia. , 2003, The Brazilian journal of infectious diseases : an official publication of the Brazilian Society of Infectious Diseases.

[9]  Lucas M Bachmann,et al.  Identifying diagnostic accuracy studies in EMBASE. , 2003, Journal of the Medical Library Association : JMLA.

[10]  R. Hopstaken,et al.  Contributions of symptoms, signs, erythrocyte sedimentation rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection. , 2003, The British journal of general practice : the journal of the Royal College of General Practitioners.

[11]  A de Roux,et al.  C-reactive protein levels in community-acquired pneumonia , 2003, European Respiratory Journal.

[12]  Victor M Montori,et al.  Conducting systematic reviews of diagnostic studies: didactic guidelines , 2002, BMC medical research methodology.

[13]  E Svedström,et al.  Differentiation of bacterial and viral pneumonia in children , 2002, Thorax.

[14]  J. Daurès,et al.  Management of lower respiratory tract infections by French general practitioners: the AIR II study , 2002, European Respiratory Journal.

[15]  H. Syrjälä,et al.  Severity assessment of lower respiratory tract infection in elderly patients in primary care. , 2001, Archives of internal medicine.

[16]  Douglas G Altman,et al.  Systematic reviews in health care: Assessing the quality of controlled clinical trials. , 2001, BMJ.

[17]  P. H. Petersen,et al.  [A randomized controlled trial of the use of CRP rapid test as a guide to treatment of respiratory infections in general practice]. , 2001, Ugeskrift for laeger.

[18]  M. Leinonen,et al.  role of serum troponin levels combined with electrocardiographic findings Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines , 2001 .

[19]  J. Macfarlane,et al.  Symptoms, signs, and prescribing for acute lower respiratory tract illness. , 2001, The British journal of general practice : the journal of the Royal College of General Practitioners.

[20]  M. Leinonen,et al.  Prospective study of the incidence, aetiology and outcome of adult lower respiratory tract illness in the community , 2001, Thorax.

[21]  A R Jadad,et al.  What contributions do languages other than English make on the results of meta-analyses? , 2000, Journal of clinical epidemiology.

[22]  O. Ruuskanen,et al.  Serum procalcitonin, C‐reactive protein and interleukin‐6 for distinguishing bacterial and viral pneumonia in children , 2000, The Pediatric infectious disease journal.

[23]  L. Hansson,et al.  Procalcitonin and C-Reactive Protein Levels in Community-Acquired Pneumonia: Correlation with Etiology and Prognosis , 2000, Infection.

[24]  Tarja Heiskanen-Kosma, Matti Korppi.  Serum C-reactive Protein Cannot Differentiate Bacterial and Viral Aetiology of Community-acquired Pneumonia in Children in Primary Healthcare Settings , 2000, Scandinavian journal of infectious diseases.

[25]  P. Bossuyt,et al.  Empirical evidence of design-related bias in studies of diagnostic tests. , 1999, JAMA.

[26]  Chio Cc,et al.  Applications of acute phase reactants in infectious diseases. , 1999 .

[27]  H. Johnson,et al.  Applications of acute phase reactants in infectious diseases. , 1999, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[28]  W. McIsaac,et al.  Are antibiotics effective treatment for acute bronchitis? A meta-analysis. , 1998, The Journal of family practice.

[29]  M. Leinonen,et al.  Etiology of childhood pneumonia: serologic results of a prospective, population-based study. , 1998, The Pediatric infectious disease journal.

[30]  M. Fine,et al.  Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. , 1997, JAMA.

[31]  M. Leinonen,et al.  White blood cells, C-reactive protein and erythrocyte sedimentation rate in pneumococcal pneumonia in children. , 1997, The European respiratory journal.

[32]  F P Ottes,et al.  Statistical Comparison of ROC Curves from Multiple Readers , 1996, Medical decision making : an international journal of the Society for Medical Decision Making.

[33]  B. Lipworth,et al.  C-reactive protein. A clinical marker in community-acquired pneumonia. , 1995, Chest.

[34]  M. Leinonen,et al.  Erythrocyte sedimentation rate, white blood cell count and serum C-reactive protein in assessing etiologic diagnosis of acute lower respiratory infections in children. , 1995, The Pediatric infectious disease journal.

[35]  B. Lipworth,et al.  C-reactive protein in simple community-acquired pneumonia. , 1995, Chest.

[36]  A. Ortqvist,et al.  Diagnostic and prognostic value of interleukin-6 and C-reactive protein in community-acquired pneumonia. , 1995, Scandinavian journal of infectious diseases.

[37]  C. Pal,et al.  Inflammatory markers of lower respiratory tract infection in elderly people. , 1994, Age and ageing.

[38]  B Littenberg,et al.  A Meta-analytic Method for Summarizing Diagnostic Test Performances , 1993, Medical decision making : an international journal of the Society for Medical Decision Making.

[39]  T. Schaberg,et al.  Diagnostic problems in lower respiratory tract infections. , 1993, The Journal of antimicrobial chemotherapy.

[40]  J. Macfarlane,et al.  Prospective study of aetiology and outcome of adult lower-respiratory-tract infections in the community , 1993, The Lancet.

[41]  M. Korppi,et al.  C-reactive protein in viral and bacterial respiratory infection in children. , 1993, Scandinavian journal of infectious diseases.

[42]  K. Dale,et al.  Diagnosis of pneumonia in adults in general practice. Relative importance of typical symptoms and abnormal chest signs evaluated against a radiographic reference standard. , 1992, Scandinavian journal of primary health care.

[43]  B. Berdal,et al.  Pneumonia--a clinical or radiographic diagnosis? Etiology and clinical features of lower respiratory tract infection in adults in general practice. , 1992, Scandinavian journal of infectious diseases.

[44]  H. Melbye,et al.  Laboratory tests for pneumonia in general practice: the diagnostic values depend on the duration of illness. , 1992, Scandinavian journal of primary health care.

[45]  W. Boersma,et al.  Pneumococcal capsular antigen detection and pneumococcal serology in patients with community acquired pneumonia. , 1991, Thorax.

[46]  P. Urdal,et al.  C-reactive protein: a new rapid assay for managing infectious disease in primary health care. , 1991, Scandinavian journal of primary health care.

[47]  B. Young,et al.  C‐Reactive Protein: A Critical Review , 1991, Pathology.

[48]  P. Heinrich,et al.  Acute‐phase response of human hepatocytes: Regulation of acute‐phase protein synthesis by interleukin‐6 , 1990, Hepatology.

[49]  B. Walia,et al.  Value of C-reactive protein concentration in diagnosis and management of acute lower respiratory infections. , 1989, Tropical and geographical medicine.

[50]  H. Melbye,et al.  The diagnosis of adult pneumonia in general practice. The diagnostic value of history, physical examination and some blood tests. , 1988, Scandinavian journal of primary health care.

[51]  M. Leinonen,et al.  The aetiology of pneumonia. Application of bacterial serology and basic laboratory methods. , 1987, The Journal of infection.

[52]  N. Laird,et al.  Meta-analysis in clinical trials. , 1986, Controlled clinical trials.

[53]  R. Ablow,et al.  Value of the C-reactive protein test in the differentiation of bacterial and viral pneumonia. , 1978, The Journal of pediatrics.

[54]  Jacob Cohen.  A Coefficient of Agreement for Nominal Scales , 1960 .

[55]  A. Gautier,et al.  C-reactive protein , 2005 .