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Trop Med Int Health. 2020 Mar;25(3):291-300. doi: 10.1111/tmi.13358. Epub 2020 Jan 6.

Sensitivity of C-reactive protein for the identification of patients with laboratory-confirmed bacterial infections in northern Tanzania.

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Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.
Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
Kilimanjaro Christian Medical University College, Moshi, Tanzania.
Duke Global Health Institute, Durham, NC, USA.
Mawenzi Regional Referral Hospital, Moshi, Tanzania.
Special Programme for Research and Training in Tropical Diseases, WHO, Geneva, Switzerland.
Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA.
Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
Intermountain Central Laboratory, Intermountain Healthcare, Murray, UT, USA.
Centre for International Health, University of Otago, Dunedin, New Zealand.
Programme in Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore.


in English, French


Identifying febrile patients requiring antibacterial treatment is challenging, particularly in low-resource settings. In South-East Asia, C-reactive protein (CRP) has been demonstrated to be highly sensitive and moderately specific in detecting bacterial infections and to safely reduce unnecessary antibacterial prescriptions in primary care. As evidence is scant in sub-Saharan Africa, we assessed the sensitivity of CRP in identifying serious bacterial infections in Tanzania.


Samples were obtained from inpatients and outpatients in a prospective febrile illness study at two hospitals in Moshi, Tanzania, 2011-2014. Bacterial bloodstream infections (BSI) were established by blood culture, and bacterial zoonotic infections were defined by ≥4 fold rise in antibody titre between acute and convalescent sera. The sensitivity of CRP in identifying bacterial infections was estimated using thresholds of 10, 20 and 40 mg/l. Specificity was not assessed because determining false-positive CRP results was limited by the lack of diagnostic testing to confirm non-bacterial aetiologies and because ascertaining true-negative cases was limited by the imperfect sensitivity of the diagnostic tests used to identify bacterial infections.


Among 235 febrile outpatients and 569 febrile inpatients evaluated, 31 (3.9%) had a bacterial BSI and 61 (7.6%) had a bacterial zoonosis. Median (interquartile range) CRP values were 173 (80-315) mg/l in bacterial BSI, and 108 (31-208) mg/l in bacterial zoonoses. The sensitivity (95% confidence intervals) of CRP was 97% (83%-99%), 94% (79%-98%) and 90% (74%-97%) for identifying bacterial BSI, and 87% (76%-93%), 82% (71%-90%) and 72% (60%-82%) for bacterial zoonoses, using thresholds of 10, 20 and 40 mg/l, respectively.


C-reactive protein was moderately sensitive for bacterial zoonoses and highly sensitive for identifying BSIs. Based on these results, operational studies are warranted to assess the safety and clinical utility of CRP for the management of non-malaria febrile illness at first-level health facilities in sub-Saharan Africa.


Afrique subsaharienne (ASS); C-reactive protein (CRP); antibacterial prescription; bacterial infection; fever; fièvre; infection bactérienne; prescription antibactérienne; protéine C-réactive (CRP); sub-Saharan Africa (SSA)

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