ORIGINAL ARTICLE

Dierentiating sepsis from non-infective

systemic inammatory response syndrome:
Comparison between C-reactive protein and Leptin
N.A. Farag
a
, K.M. Taema
b,
*
, E. Abdel-Lati
b
, G. Hamed
b
a
Critical Care Medicine, Elsahel Teaching Hospital, Cairo, Egypt
b
Critical Care Medicine, Cairo University, Cairo, Egypt
Received 15 May 2013; revised 15 November 2013; accepted 16 November 2013
Available online 5 December 2013
KEYWORDS
Sepsis;
SIRS;
Leptin;
CRP
Abstract Background: Differentiation of sepsis from non-infectious SIRS is important in improv-
ing sepsis outcome. We intended in this study to evaluate the role of serum Leptin and to compare it
with CRP in differentiating sepsis from non-infectious SIRS.
Methods: We included 30 patients with SIRS. According to the presence or absence of infection,
our patients were classied into SIRS group and sepsis group. Leptin and CRP were evaluated in all
patients on admission, day 2 and day 4.
Results: Our patients had a mean age of 52.3 18.6 year old, 10 males (33.3%). There were no
signicant differences regarding baseline demographic and clinical data apart from blood pressures
which were lower in the sepsis group. Serum Leptin on Day 2 only was higher in the sepsis group
(44.2 17.7 lg/L vs. 31.1 2.1 lg/L, P = 0.008) with no difference in days 0 and 4 of admission.
We detected a serum Leptin level of 38.05 lg/L on day 2 to be 93% sensitive and 100% specic to
diagnose sepsis. The three serum CRP levels were higher in sepsis compared to SIRS group
(61.2 9 mg/L vs. 48.9 7.1 mg/L, P < 0.001 in day 0, 71.5 9.6 mg/L and 196.8 39.8 mg/
L in sepsis group vs. 56.9 8 mg/L and 73.7 32.5 mg/L in SIRS group for days 2 and 4 respec-
tively, P < 0.001 for both). We found a CRP of 67.5 mg/L on day 2 having 87% sensitivity and
*
Corresponding author. Tel.: +20 1000412603.
E-mail addresses: Khaled.toaima@kasralainy.edu.eg, Khaledtoai-
ma@assih.com (K.M. Taema).
Peer review under responsibility of The Egyptian College of Critical
Care Physicians.
Production and hosting by Elsevier
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93% specicity for the diagnosis of sepsis.
Conclusion: We concluded that despite serum Leptin may not be benecial in early differentia-
tion between sepsis and non infectious SIRS on admission; it may be highly specic on second day.
2013 Production and hosting by Elsevier B.V. on behalf of The Egyptian College of Critical Care
Physicians.
Introduction
Despite the use of modern management strategies, sepsis is a
leading cause of death in critically ill patients [1]. The septic re-
sponse is an extremely complex chain of events involving
inammatory and anti-inammatory processes, humoral and
cellular reactions and circulatory abnormalities [2,3].
The diagnosis of sepsis and evaluation of its severity are
complicated by the highly variable and non-specic nature of
the signs and symptoms of sepsis [4]. However, the early diag-
nosis and stratication of the severity of sepsis are very impor-
tant, increasing the possibility of starting timely and the
specic treatment [5,6].
Leptin is an adipokine that reveals pleiotropic neurohumo-
ral function, which regulates appetite and energy expenditure
via the hypothalamicpituitaryadrenal axis, vascular func-
tion, bone and cartilage growth, and pregnancy. It is also an
important immunoregulatory hormone that enhances a num-
ber of immune responses, including macrophage effector func-
tions and cytokine synthesis [7]. Leptin level was found to
increase in response to infection and inammatory stimuli [8].
We sought to evaluate the value of Leptin in critically ill pa-
tients and to compare it with the C-reactive protein for early
diagnosis and differentiation between sepsis and non-infec-
tious systemic inammatory response syndrome (SIRS).
Patients and methods
This is a prospective study that was conducted on 30 adult crit-
ically ill patients staying for more than 24 h in the ICU (surgi-
cal/medical) department, El Sahel Teaching Hospital, Cairo,
Egypt. We included in the study patients diagnosed with SIRS
based on the 1991 ACCP/SCCM Sepsis Directory [9] and the
diagnostic criteria advanced by the 2001 International Sepsis
Denition Conference [10], exhibiting two or more of the fol-
lowing signs: (1) temperature of >38 or <36 C, (2) pulse rate
of >90 beats/min, (3) respiratory rate of >20 breaths/min or
hyperventilation with a partial pressure of arterial carbon diox-
ide (PaCO2) of <32 mmHg, or (4) white blood cell (WBC)
count of >12,000 or <4000 lL
1
, or >10% immature cells.
We excluded from the study, patients who received anti-
inammatory drugs or corticosteroids before admission, pa-
tients who had immunosuppressive illness, and patients who
had received massive blood transfusion.
The presence of infection was dened according to the clin-
ical and microbiological criteria of the CDC denitions [11]
and was held as a gold standard and determined by three inde-
pendent experts who were blinded to the serum Leptin and
CRP results and examined the patients daily for the 1st 48 h
of admission. According to the presence or absence of infec-
tion, our patients were divided into two groups; group A in-
cluded patients with non-infectious SIRS (SIRS group) and
group B included patients with infection (sepsis group).
The study protocol was approved by the institutional re-
view board at Cairo University together with representatives
of study conduction site, and a written informed consent to
participate was obtained from all participating patients or rst
degree relatives.
For all cases the following were performed
Full history taking and meticulous physical examination, with
sequential organ failure assessment (SOFA) score to be as-
sessed on admission, and days 2 and 4.
Routine laboratory investigations (e.g. complete blood
count, blood urea nitrogen, blood sugar, serum sodium, potas-
sium, calcium, aspartate aminotransferase, alanine amino-
transferase, INR, albumin) were done in the patients. Serum
biomarkers (Leptin and CRP levels) were done on admission,
and days 2 and 4. Routine cultures of blood, sputum, urine,
and suspected sites of infection were obtained.
All patients were managed by conventional supportive mea-
sures for critically ill patients including uids, oxygen therapy,
and ventilatory support whenever required. However, when-
ever criteria of infection appeared or suspected (according to
CDC and guided by Surviving sepsis campaign guidelines),
antibiotics were immediately instituted even in SIRS patients.
Leptin assay
Blood samples were collected aseptically by venipuncture 3
times (on admission and on days 2 and 4 of admission). The
blood was then left to clot then centrifuged for 15 min at
5000 rpm. The sera were separated and stored at 20 C until
the time of the assay.
Serum Leptin was determined by quantitative sandwich en-
zyme immunoassay (USA) according to the manufacturers
instructions. The assay is an ELISA format, performed in
microwells coated with anti-Leptin antibody (monoclonal).
Leptin present in a measured volume of sample or calibrator
will bind to the anti-Leptin antibody on the microtitre plate.
Non-bound material was removed by washing. Subse-
quently, a horseradish peroxidase (HRP) conjugated antibody
to Leptin is added. After removal of non-bound conjugate by
washing, substrate solution is added to the wells. The color
that develops is proportional to the amount of Leptin present
in sample or calibrator.
The enzymatic reaction is stopped chemically and the color
intensity is read at 450 nm in an ELISA reader. From the
absorbance of the samples and those of a calibration curve,
the concentration of Leptin is determined by interpolation.
Statistical analysis
Data were prospectively collected and coded prior to analysis
using the professional statistical Package for Social Science
112 N.A. Farag et al.
(SPSS version 16). Continuous variables were expressed as
mean and standard deviation (SD). Categorical variables were
expressed as frequency and proportion. Student-t Test (t) was
used for comparison between two groups as regards normally
distributed (parametric) quantitative data. Chi-Square Test
(v
2
) was used for comparison between two groups as regards
qualitative data. Results were considered statistically signi-
cant if P 6 0.05. A receiver operating characteristic (ROC)
analysis was performed to dene a cutoff value of different
markers.
Results
During the period between August 2011 and February 2012,
thirty critically ill patients with expected length of stay more
than 24 h in the surgical/medical ICU in El Sahel Teaching
Hospital were enrolled in the study. Our patients had a mean
age of 52.3 18.6 year old, including 10 males (33.3%) and 20
females (66.6%). After enrollment, our patients were classied
into two groups according to the diagnosis that included non-
infective SIRS group and sepsis group.
Each group comprised 15 patients; patients demographics
and baseline clinical data are shown in Table 1. The presence
or absence of co-morbid conditions as well as cause of ICU
admission being medical or surgical was similar in both groups
(Table 1). The causes of ICU admission are illustrated in
Table 2.
As shown in Table 3, there was no signicant difference be-
tween both groups regarding clinical and laboratory data, ex-
cept higher systolic blood pressure (SBP), diastolic blood
pressure (DBP), mean blood pressure (MBP), and P/F ratio
and lower heart rate (HR), respiratory rate, serum creatinine,
and INR in SIRS group compared to sepsis group.
We found that the serum Leptin levels on days 2 and 4 in
the SIRS group were positively correlated with the SOFA
score (r = 0.76, P = 0.002 and r = 0.67, P = 0.006 respec-
tively). Meanwhile, all three samples of serum CRP levels
(on admission and on days 2 and 4) were correlated positively
with the SOFA score (r = 0.75, P = 0.002; r = 0.67,
P = 0.009; and r = 0.64, P = 0.01 respectively). On the other
hand, in the sepsis group, neither the Leptin nor the CRP re-
vealed a correlation with the SOFA score (r = 0.39, P = 0.2;
r = 0.36, P = 0.2; and r = 0.15, P = 0.6 for admission and
days 2 and 4 of Leptin respectively and r = 0.38, P = 0.2;
r = 0.4, P = 0.13; and r = 0.22, P = 0.43 for CRP
respectively).
Table 4 shows a higher incidence for the need of mechanical
ventilation and use of inotropic and/or vasoactive support in
the sepsis group than in the SIRS group. There was also signif-
icantly higher SOFA score in the sepsis group.
Serum Leptin and serum CRP were compared in both
groups on days 0, 2, and 4. Serum Leptin level on admission
revealed a modest non signicant higher level in the sepsis
group (3.5 0.9 lg/L vs. 3 0.7 lg/L, P = 0.1) while on
Table 1 Baseline demographic and clinical data.
SIRS Sepsis P-value
Age 51.3 16 53.3 21.3 0.77
Gender [N (%)]
Male 6 (40%) 4 (26.7%) 0.35
Female 9 (60%) 11 (73.3%)
BMI 23.9 2.4 24.3 3.7 0.7
HTN [N (%)] 8 (53.3%) 7 (46%) 0.8
DM [N (%)] 10 (66.7%) 7 (46%) 0.47
CVS [N (%)] 2 (13.3%) 1 (6.66%) 0.56
CRF [N (%)] 1 (6.66%) 2 (13.3%) 0.56
CHF [N (%)] 0 (0%) 1 (6.66%) 0.32
Co-morbidity
1 co-morbidity 3 3 0.68
2 co-morbidities 3 5
More than two co-morbidities 9 7
Cause of admission
Medical 12 12 0.67
Surgical 3 3
BMI: body mass index, HTN: hypertension, DM: diabetes mellitus, CVS: cerebrovascular stroke, CRF: chronic renal failure, CLD: chronic
lung disease, CHF: congestive heart failure.
Table 2 Causes of admission in both groups.
SIRS N (%) Sepsis N (%) Total
Respiratory distress
Pneumonia 0 (0 %) 7 (46.7 %) 7 (23.3 %)
Acute lung injury 4 (26.7 %) 0 (0 %) 4 (13.3 %)
Bronchogenic carcinoma 1 (6.7 %) 0 (0 %) 1 (3.3 %)
Abdominal sepsis 0 (0 %) 1 (6.7 %) 1 (3.3 %)
Suspected central line
infection
1 (6.7 %) 1 (6.7 %) 2 (6.7 %)
Soft tissue infection 0 (0 %) 1 (6.7 %) 1 (3.3 %)
Urinary tract infection 0 (0 %) 2 (13.3%) 2 (6.7 %)
DKA 3 (20 %) 0 (0 %) 3 (10 %)
Post-operative 3 (20 %) 3 (20 %) 6 (20 %)
Intestinal obstruction 1 (6.7 %) 0 (0 %) 1 (3.3 %)
Hematologic malignancy 1 (6.7 %) 0 (0 %) 1 (3.3 %)
CRF with volume overload 1 (6.7 %) 0 (0 %) 1 (3.3 %)
Total 15 (100 %) 15 (100 %) 30 (100 %)
DKA: diabetic ketoacidosis, CRF: chronic renal failure.
Differentiating sepsis from non-infective systemic inammatory response syndrome 113
Day 2 the serum Leptin level was signicantly higher in the
sepsis group compared to the SIRS group (44.2 17.7 lg/L
vs. 31.1 2.1 lg/L, P = 0.008). This signicant difference dis-
appeared again on day 4 where there was no signicant differ-
ence between the two groups (18.2 3.9 lg/L in sepsis group
compared to 17 1.4 lg/L in SIRS group, P = 0.23) (Fig. 1).
Serum Leptin level of 38.05 lg/L on second day of admission
was found to have a sensitivity of 93% and a specicity of
100% for the diagnosis of sepsis with a positive predictive va-
lue (PPV) of 100% and a negative predictive value (NPV) of
94% (Fig. 2).
Serum CRP level on admission was 61.2 9 mg/L in the
sepsis group compared to 48.9 7.1 mg/L in the SIRS group
which is a statistically signicant difference (P < 0.001)
(Fig. 3). Day 2 and day 4 serum levels of serum CRP were also
signicantly higher in the sepsis group than in the SIRS group
(71.5 9.6 mg/L and 196.8 39.8 mg/L vs. 56.9 8 mg/L
and 73.7 32.5 mg/L respectively, P < 0.001 for both)
(Fig. 3). We found a serum CRP level of 51 mg/L on the day
of admission to have 93% sensitivity, 80% specicity, 82%
PPV, and 92% NPV for the diagnosis of sepsis (Fig. 4) and
a level of 67.5 mg/L on day 2 to have 87% sensitivity, 93%
specicity, 93% PPV, and 88% NPV for the diagnosis of sepsis
(Fig. 5). The serum CRP on day 4 of 95.5 mg/L has a sensitiv-
ity and specicity of 93% and PPV and NPV of 93% for the
diagnosis of sepsis (Fig. 6).
Only 2 patients (in the sepsis group) died in our study and
had a Leptin of 3.1 and 38.5 lg/L and a CRP of 65 and 73 mg/
L on admission and day 2.
Discussion
Severe sepsis is the most common cause of death for patients
admitted to the critical care units [1]. The early diagnosis of
sepsis, the identication of its origin, and an adequate thera-
peutic management are crucial to overcome sepsis-associated
mortality. So, the matter at heart in the early differentiation
Table 3 Baseline clinical and laboratory data.
SIRS Sepsis P-value
HR 111.6 14.4 124.8 18.8 0.04
SBP 112.33 23.7 90.67 20.5 0.012
DBP 69.33 14.7 54 11.8 0.004
MBP 83.7 16.8 66.2 14.2 0.005
RR 25.7 3.7 34.5 8.7 0.001
Temperature 38 1 38.9 1.7 0.078
CVP 6.3 3.2 4 4.5 0.17
ScvO
2
72.3 6.3 67.4 14.8 0.25
Serum urea 67.3 52.8 91.2 79.9 0.34
Serum Creatinine 1.7 0.98 3.4 2.2 0.01
Na
+
133.2 5.2 135.9 7.3 0.25
K
+
3.9 0.8 3.5 0.5 0.095
Ca
++
8.3 0.8 7.8 1.6 0.32
RBG 199.7 64.6 284.3 163.6 0.07
AST 78.9 110.4 95.9 106.9 0.67
ALT 38.2 22.4 88 118.1 0.12
Serum albumin 3.1 0.8 3.2 0.5 0.9
INR 1.4 0.32 1.97 0.86 0.04
Hemoglobin 11 2.8 10.9 2.3 0.85
Platelet count 199.3 107.9 226 137 0.55
TLC 14.8 5.9 19.3 8.5 0.09
P/F ratio 373.93 61.7 263.27 95.7 0.001
Table 4 Need of mechanical ventilation, use of inotropic and/or vasoactive support, and SOFA score in both groups.
SIRS Sepsis P-value
Mechanical ventilation [N (%)] Yes 0 (0 %) 9 (60 %) 0.002
No 15 (100%) 6 (40 %)
Use of inotropic and/or vasoactive support [N (%)] Yes 2 (13.3 %) 7 (47 %) 0.05
No 13 (86.6 %) 8 (53 %)
SOFA score Mean SD 5 3 8 3 0. 02
Figure 1 Serum Leptin during days 0, 2, and 4 in both groups.
Figure 2 ROC curve for cut-off value of serum Leptin of day 2.
114 N.A. Farag et al.
between Sepsis and non-infectious SIRS is the impact on
outcome.
The adipokine Leptin regulates energy expenditure, vascu-
lar function, bone and cartilage growth as well as the immune
system and systemic inammatory response. Several activating
effects toward T cells, monocytes, endothelium cells and cyto-
kine production have been reported suggesting a protective
role of Leptin in the setting of an acute systemic inammation
[7,12]. Some studies found that serum Leptin is a powerful bio-
marker that helps to differentiate sepsis from the non-infec-
tious SIRS in critically ill patients with higher levels in sepsis
[8,1315].
We intended in this study to evaluate the value of monitor-
ing serum Leptin in critically ill patients and to compare it with
serum CRP for early diagnosis of sepsis and its differentiation
from non-infectious SIRS.
Both groups of the study had comparable demographic
data and comorbidities, however data of disease severity were
signicantly worse in the sepsis group e.g. HR, MAP, RR,
and need of mechanical ventilation and vasoactive support
that was reected on higher SOFA score. Higher heart
rate and lower blood pressures were also reported by many
investigators in patients with denite bacterial infection
[1618]. This was attributed by many authors to the well
known systemic vasodilation and myocardial depression that
occurs in sepsis. Endothelium dysfunction, inammatory
cytokines release, and inducible NO synthase mediated NO
release are involved in sepsis associated profound vasodilation
and biventricular failure [1921].
Respiratory rate was signicantly higher in sepsis than
SIRS groups and this is in agreement with other studies in
which patients with sepsis had higher RR and rapid shallow
breathing index [18,22]. They explained this by reduced respi-
ratory muscle capacity and increased load. The negative im-
pact of sepsis on respiratory muscle function was attributed
to circulating mediators [23], changes in intracellular calcium
[24], oxygen metabolism [25], or changes in respiratory muscle
ultrastructure [26]. These effects, however, could happen in
critical illness irrespective of sepsis.
According to these differences in blood pressures, heart
rate, and respiratory rate, it is not surprising that the use of
inotropic and vasoactive supports and the need for mechanical
ventilation and subsequently SOFA score were signicantly
higher in the sepsis group. Higher SOFA score in sepsis was
reported in some other studies [8,27,28]. Despite these signi-
cant differences of clinical and laboratory data that were ob-
served in our study and in others, Shapiro et al, [29] showed
that these data are not pathognomonic for infection and
may also be observed in a wide variety of noninfectious inam-
matory conditions. In addition, they may be absent in patients
with serious infections, especially in elderly individuals [29].
Our results showed that serum Leptin level on 2nd day and
not on admission can differentiate between sepsis and non-
infectious SIRS. We found a serum Leptin level of 38.05 lg/
L on second day of admission to diagnose sepsis in patients
admitted with SIRS with a sensitivity of 93% and a specicity
of 100%.
Torpy et al., [13] reported a higher Leptin level in septic
patients on the day of admission. Arnalich et al., [14] even
found that the admission serum Leptin was higher in patients
Figure 3 Serum CRP during days 0, 2, and 4 in both groups.
Figure 5 ROC curve for cut-off value of serum CRP of day 2.
Figure 4 ROC curve for cut-off value of serum CRP of day 0.
Differentiating sepsis from non-infective systemic inammatory response syndrome 115
with septic shock than patients with severe sepsis without
shock [14].
Similar to our results, Yousef et al, [8] showed that the
admission serum Leptin was nearly equal among patients in
the sepsis, SIRS, and non-SIRS groups and that the second
day levels signicantly increased in septic and SIRS patients
compared to non-SIRS patients. They detected a cut-off serum
Leptin level of 38 lg/L with a sensitivity of 91.2% and a spec-
icity of 85% to identify sepsis from SIRS [8]. Cesur et al, [15]
also stated that there was no statistically signicant difference
between the patient group with sepsis and the control group in
terms of serum Leptin levels on admission but Leptin was
higher in patient group with sepsis on days 3 and 5.
This reported rise in serum Leptin concentration following
acute infection suggests that it may actively participate in the
immune response and host defense. Leptin and its receptors
have structural similarities with cytokine family that includes
IL-6 and IL-12 [30,31], so it should not be surprising that it
acts as a pro-inammatory cytokine. Leptin itself was shown
by some authors to increase the production of TNF a and
IL-6 from macrophages [12].
Contrary to these results, Carlson et al showed that sepsis
was not associated with signicant change in serum Leptin
concentration [32]. The population of this study was however
not comparable with ours as patients were enrolled in the
study after about 14 days of sepsis diagnosis. This delay in
time of enrollment relative to sepsis onset could explain these
differences as other authors had identied an increase in serum
Leptin concentration for only the rst 5 days following pro-
longed administration of IL-1a [33]. On the other hand, many
of the studies that concluded an elevated serum Leptin in re-
sponse to sepsis including ours did not report on body compo-
sition or feeding regimens that might conceivably have
inuenced the results.
On the extreme, Langouche et al in [34] even showed low
serum Leptin levels in critically ill patients that were postulated
by the authors to be due to an acute stress response. This study
was planned to evaluate the effect of conventional and intense
insulin therapy on serum Leptin. So, like Carlson and cowork-
ers [32], they screened prolonged critically ill patients and an
early effect may have been missed. Another explanation of this
discrepancy could be attributed to differences in illness severity
between their population and ours. Langouche and his col-
leagues [34] reported high death rates that were 51.5% in pa-
tients with sepsis while only two of our sepsis group
population died (13.3%). Many authors showed an association
between low serum Leptin level and mortality [14] as Leptin
was found to stimulate proliferation of lympho-hematopoetic
cells and phagocytic activity of macrophages [35].
We detected in this study that the serum CRP levels on
admission, 2nd day, and 4th day following admission were sig-
nicantly higher in sepsis compared to non-infectious SIRS.
Many other studies [17,27,36] showed that a high serum
CRP concentration in patients within 24 h of admission to hos-
pital is indicative of sepsis and can differentiate septic patients
from non-infectious SIRS. Yousef et al, [8] however showed
that despite the mean values of CRP on admission cannot dif-
ferentiate between the two groups, the CRP level on the 4th
day of admission was signicantly higher in sepsis compared
to non-infectious SIRS groups [8].
C reactive protein production is a part of a larger picture of
the acute phase response. This is principally regulated by the
cytokines IL-6 [37], Tumor necrosis factor a, and IL-1b are
also regulatory mediators of CRP synthesis [38]. C-reactive
protein is directly involved in clearance of microorganisms
[39]. It causes activation of neutrophils and enhances NK cell
activity [40,41].
We detected a CRP level of 51 mg/L on the day of admis-
sion to have 93% sensitivity and 80% specicity for the
diagnosis of sepsis. Many other investigators described CRP
cut-off values for detection of sepsis. Povoa et al detected also
a level of 50 mg/L with sensitivity of 98.5% and specicity of
75% [42]. Liu et al, [17] found a value of 60 mg/L with a sen-
sitivity of 80.7% and specicity of 96.0% for diagnosing bac-
terial infection. Higher cut-off values were reported by other
authors. Sierra et al, [43] showed the cut-off value of 80 mg/
L is 94.3% sensitive and 87.3% specic for sepsis [43] however
Miller and his colleagues reported a higher value of 170 mg/L
for CRP with 100% specicity [44].
In a study on postoperative patients, the investigators
found that the CRP started to be elevated 12 h and peaked
36 h after the operation [45]. Other authors reported that the
CRP starts to elevate within 46 h of stimulus and doubles
every 8 h to reach a peak at 3650 h [39]. On the other hand,
Leptin was found to start being elevated and peaked 24 h after
stimulus [45]. This could explain the lack of signicance of ser-
um Leptin between both groups in our study on admission and
on day 4 but the only signicance was on day 2.
Despite the detection of an early serum CRP on admission
of 51 mg/L to have 80% specicity for the diagnosis of sepsis,
the later serum Leptin on day 2 of 38.05 lg/L was found to
have 100% specicity. The late yet more specic elevation of
serum Leptin level in sepsis needs to be further evaluated.
Conclusion
Serum CRP level can differentiate early between sepsis and
non infectious SIRS on admission, however on the second
Figure 6 ROC curve for cut-off value of serum CRP of day 4.
116 N.A. Farag et al.
day of admission the use of elevated serum Leptin level may be
more specic than elevated CRP level either on admission or
on second day in identifying sepsis patients.
Study limitations
Limitations of this study included the limited number of sam-
ples of the biomarkers (only three samples) that may have
missed higher levels. Some other studies screened Leptin in
6 h intervals; however we aimed at evaluating the patients on
admission. Another limitation was the limited number of pa-
tients included in the study; further studies are needed to con-
rm our results. Finally, Antibiotics had to be given early in
some patients with SIRS with no obvious infection, for the
possibility of hidden infection, which may have had an impact
on the markers. In other patients in which infection appeared
later could have had an occult infection that aggravated rather
than a superadded infection, and may not have been appropri-
ately assigned.
Conict of interest
None declared.
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