C-Reactive Protein: a Prognosis Factor for Septic Patients Systematic Review and Meta-analysis

1. C-Reactive Protein: a Prognosis Factor for Septic PatientsSystematic Review and Meta-analysis Introduction to Medicine – 1st Semester Class 4, First Year Prof. Doutor Armando Teixeira-Pinto Prof. DoutorAltamiro Costa-Pereira

2. C-ReactiveProtein: a Prognosis Factor for SepticPatients Summary 1) Introduction 2) Studies 3) Problem / ResearchQuestion 4) Key-Words 5) Aims • 6) Methods • 6.1) Query • 6.2) Criteria • 6.3) Research • 6.4)SelectionofStudies • 7) ExpectedResults • 8) Balance

3. C-Reactive Protein: a Prognosis Factor for Septic Patients Introduction • Sepsis (systematic inflammatory response syndrome with a proven or suspected infectious etiology) is a very serious disease, so we found interesting to investigate if C-reactive protein (a plasmaproteinthatcirculatesinincreasedamountsduringinflammationandaftertissuedamage) can really predict the evolution of the disease and if its levels help to decide which therapy should be applied to patients.

4. C-Reactive Protein: a Prognosis Factor for Septic Patients Introduction • Among the studies we found there are some controversy about the relevance of C-reactive protein as a good prognosis factor for sepsis. • Study 1: The Time Course of Blood C-reactive Protein Concentrations in Relation to the Response to Initial Antimicrobial Therapy in Patients with Sepsis; • Study 2:High C-reactive Protein and Low Cholesterol Levels are Prognostic Markers of Survival in Severe Sepsis; • Study 3:Procalcitonin for Early Prediction of Survival Outcome in Postoperative Critically ill Patients with Severe Sepsis.

5. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies

6. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies Study 1: The Time Course of Blood C-reactive Protein Concentrations in Relation to the Response to Initial Antimicrobial Therapy in Patients with Sepsis • Aim: Measure changes to look for the response treatment based on C-reactive protein blood levels in septic patients. • Details • 5 months (from 11/2005 to 04/2006); • 2 hospitals in Brussels, Belgium. • 50 patients were included since the day of septic diagnosis until time of administration of first antibiotic dose (D0); they were observed daily until death, transfer to the general floor or seventh day (D7).

7. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies • MethodsandResults: Patients were divided into three groups: • - BloodCRPconcentrationsweredeterminedbyimmunoturbidimetry.

8. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies • Conclusions: • - IncreasesinCRPconcentrationsareassociatedwithorganfailure, prolongedICUstayandhighmortality; • - CRPconcentrationsdecreasearefasterandmoresignificantinpatientswith a goodresponsetotheinitialtreatmentthaninthosewhorequired a changeinantibiotictherapy; • - However, CRPconcentrationsinpatientsatthe “septicshock” phaseareconclusivethatC-reactiveproteinisn’thelpfulinpredictingmortality. • Schmit, X. et al., The Time Course of Blood C-reactive Protein Concentrations in Relation to the Response to Initial Antimicrobial Therapy in Patients with Sepsis, Infection 36 Æ 2008 Æ No. 3

9. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies Study 2: High C-reactive Protein and Low Cholesterol Levels are Prognostic Markers of Survival in Severe Sepsis • Aim: Evaluate the predictive value of cholesterol and C-reactive protein levels on the mortality and morbidity of severe sepsis. • Details • Prospectivestudy; • 96 patients (age range, 18-75 years; median, 56 years; men/women ratio, 40:56) diagnosedwithseveresepsis. • Methods: • Patients' serum levels of C-reactive protein and cholesterol were measured thrice: upon admission to an intensive care unit, two days later, and on the day of discharge from the intensive care unit or on the day of death.

10. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies • Results: • • Conclusions: • Table constructed based on the results of the study: • Memiş D et al. High C-reactive protein and low cholesterol levels are prognostic markers of survival in severe sepsis. 2007 May;19(3):186-91.

11. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies Study 3: Procalcitonin for early prediction of survival outcome in postoperative critically ill patients with severe sepsis. • Aim: Assess the utility of procalcitonin (PCT), C-reactive protein and other readilyavailable parameters, as useful early (days 1–3) predictorsof mortality in postoperative patients diagnosed with severesepsis. • Details: • Period of 2 years; • In ICU, were admitted 69 postoperativepatients with severe sepsis and 890 non-septic. • Methods: • PCT, C-reactive protein (CRP) andsequential organ failure assessment (SOFA) score were recordedover the duration of ICU stay.

12. C-Reactive Protein: a Prognosis Factor for Septic Patients Studies • Results: • Area underROC (receiver operating characteristic) curves on day 3 of CRP (0.61) was non-predictive and remainednon-predictive over the duration of ICU stay. • • Conclusion: • According to thisstudy, C-reactiveproteinisn’t a goodfactorofprognosisamongsepticpatients. • Dahaba, A. A. et al. Procalcitonin for early prediction of survival outcome in postoperative critically ill patients with severe sepsis. 2006 June 14

13. C-Reactive Protein: a Prognosis Factor for Septic Patients Problem / ResearchQuestion • “IsC-reactiveprotein a good factor ofprognosis for septicpatients?” • - “ Are thelevelsofthisproteinrelated to the degree of severity of sepsis?” • - “How can those values influence a good prognosis?” • - “Can it predict the mortality among those patients?”

14. C-Reactive Protein: a Prognosis Factor for Septic Patients Key-Words C-reactive protein Prognosis Sepsis

15. C-Reactive Protein: a Prognosis Factor for Septic Patients Aims

16. C-Reactive Protein: a Prognosis Factor for Septic Patients Methods

17. C-Reactive Protein: a Prognosis Factor for Septic Patients Query • The search terms will include the following, their synonymous and, when applicable, equivalent MeSH terms: ["C-reactive protein”] AND [“prognosis”] AND ["sepsis” OR “infection” OR “cross infection” OR “hospital acquired infection” OR “multiple organ dysfunction syndrome” OR “MODS” OR “ septicemia” OR “septic shock” OR “systematic inflammatory response syndrome” OR “SIRS”] • Querymayalsoinclude[“hospital” OR “critical care” OR “intensive care”].

18. C-Reactive Protein: a Prognosis Factor for Septic Patients Criteria

19. C-Reactive Protein: a Prognosis Factor for Septic Patients Research • In order to find the articles we need, we’ve searched in the following databases by inserting the key-words referred previously: • Pubmed (154 articles); • SCOPUS (search in course); • Google Scholar ( 9520 results – analysis in process).

20. C-Reactive Protein: a Prognosis Factor for Septic Patients Data Synthesis

21. C-Reactive Protein: a Prognosis Factor for Septic Patients SelectionofStudies • The decision of inclusion or exclusion of each article was taken according to the inclusion or exclusion criteria determined.

22. C-Reactive Protein: a Prognosis Factor for Septic Patients ExpectedResults Different levels of C - Reactive Protein in blood at different stages of sepsis will be related to its progression or regression. Therefore, this will assess the chances of survival of patients. • If this relation is confirmed, a most precise therapy could be chosen for each patient, according to the prognosis. • Internment time would be reduced, economical expenses would be fewer, since useless medication wouldn’t be used.

23. C-Reactive Protein: a Prognosis Factor for Septic Patients Balance • Presently • Wehavemade some meetings to managetasks; • We are improvingourresearchworkbyreadingandselectingstudies; • We are finishingthearticle’sprotocol. • Future • Research, selectandprocess more information; • Organizethegeneralstructureoftherestofthearticle (besidesprotocol) andwriteit’sfinaltext.

24. THE END Presenter: Sara Rodrigues Class 4 2008 / 2009