Diagnostic value of eosinopenia and neutrophil to lymphocyte ratio on early onset neonatal sepsis

Is neutrophil to lymphocyte ratio an accurate predictor of neonatal sepsis in premature infants?

BACKGROUND

Sepsis is a significant cause of neonatal mortality. Both clinical and laboratory markers are often non- specific, and a blood culture contaminant may confuse management of the infant. This study aims to use an existing, inexpensive test, the neutrophil-to-lymphocyte ratio (NLR), to predict culture positivity and thus optimise antibiotic management.

METHODS

Data on infants born ≤32 weeks gestation from 2015 to 2020 who were treated for sepsis were analyzed. Episodes were categorised based on culture positivity: i) positive with known pathogens, ii) true positive with coagulase-negative staphylococci (CoNS), iii) false positive with CoNS contaminants, iv) positive with other contaminants, and v) negative culture. NLR was compared with late C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR). Receiver operating curve (ROC) analysis was performed in this study. A cut- off value of 1.2 was chosen for NLR to detect culture.

RESULTS

A total of 2024 infants were included in the study, with no significant differences in demographics between groups. Infants with positive blood cultures of known pathogens had higher median NLR of 1.44 compared with those with contaminants (0.75) or negative cultures (0.84). A NLR cut-off value of 1.2 gave a sensitivity of 65.7 % and specificity of 63.7 %.The area under the curve (AUC) for NLR, late CRP and ITR were 0.71, 0.64 and 0.57 respectively. Combining NLR with late CRP would increase the AUC to 0.78 (95 % C·I 0.75-0.82, p < 0.01), whereas the addition of ITR to NLR and late CRP would not improve this. In a secondary analysis, between true and contaminant CoNS positivity, NLR and ITR could not be used to differentiate between these groups (p < 0.05 and 0.33), but late CRP could (p < 0.01).

CONCLUSIONS

Clinicians should consider the use of NLR as an adjunct biomarker to late CRP in detecting culture positive sepsis in premature neonates. The use of ITR does not improve diagnostic accuracy for sepsis.

Identification and Functional Analysis of PANoptosis-Associated Genes in the Progression From Sepsis to ARDS

BACKGROUND

Sepsis and acute respiratory distress syndrome (ARDS) are common inflammatory conditions in intensive care, with ARDS significantly increasing mortality in septic patients. PANoptosis, a newly discovered form of programmed cell death involving multiple cell death pathways, plays a critical role in inflammatory diseases. This study aims to elucidate the PANoptosis-related genes (PRGs) and their involvement in the progression of sepsis to ARDS.

METHODS

This study analyzed differentially expressed genes (DEGs) associated with PRGs to explore their role in the progression of immune disorders from sepsis to septic ARDS. A diagnostic prediction model was constructed based on key PRGs identified through bioinformatics analysis. Functional enrichment analyses were conducted to determine pathway involvement, and correlations with immune cells were assessed. Mendelian randomization analysis was applied to investigate potential causal links between specific PRGs and ARDS. Immunohistochemical analysis was used to evaluate PRG expression in lung tissue.

RESULTS

The prediction model effectively distinguished septic ARDS patients from those with sepsis. NDRG1 expression was elevated in ARDS, while DDX3X, PTPRC, and TNFSF8 were downregulated. NDRG1 showed a positive correlation with activated dendritic cells, whereas DDX3X, PTPRC, and TNFSF8 were positively associated with neutrophils and negatively correlated with CD56bright NK cells. Functional enrichment analysis highlighted spliceosome function, MAPK signaling, endocytosis, and antigen processing pathways as significantly associated with these PRGs. Mendelian randomization suggested a causal link between NDRG1 and ARDS, and immunohistochemical analysis revealed its predominant expression near vascular walls. In a mouse model of sepsis, suppression of NDRG1 alleviated lung injury.

CONCLUSION

PANoptosis may contribute to immune dysregulation in sepsis-associated ARDS. NDRG1 is identified as a potential therapeutic target, offering new avenues for mitigating ARDS progression and improving patient outcomes.

Soluble TREM-1 is not a useful biomarker in the diagnosis of early-onset neonatal sepsis

Aim: Sepsis remains a significant cause of morbidity and mortality in neonates. We aimed to investigate the use and reliability of the soluble triggering receptor expressed on myeloid cells (sTREM-1) biomarker for suspected early onset of neonatal sepsis (EONS).Materials & methods: 52 patients with suspected EONS and 30 healthy newborns were analyzed for sTREM-1 and other biomarkers.Results: It revealed that elevated levels of C-reactive protein (CRP), neutrophil (%), red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR) and lactate, as well as decreased lymphocyte (%) were statistically significant for EONS. However, there was no statistically significant difference in sTREM-1 levels between the groups.Conclusion: Although no significant difference in sTREM-1 levels was found between the groups, further research involving repeated measurements and larger sample sizes is necessary to evaluate its practical utility in clinical settings.

Diagnostic significance of complete blood cell count and hemogram-derived markers for neonatal sepsis at Southwest Public Hospitals, Ethiopia

BACKGROUND

Neonatal sepsis is defined as an infection-related condition characterized by signs and symptoms of bacteremia within the first month of life. It is the leading cause of mortality and morbidity among newborns. While several studies have been conducted in other parts of world to assess the usefulness of complete blood count parameters and hemogram-derived markers as early screening tools for neonatal sepsis, the associations between sepsis and its complications with these blood parameters are still being investigated in our setting and are not yet part of routine practice.

AIM

To evaluate the diagnostic significance of complete blood cell count hemogram-derived novel markers for neonatal sepsis among neonates attending public hospitals in the southwest region of Oromia, Ethiopia, through a case control study.

METHODS

A case control study was conducted from October 2021 to October 2023 Sociodemographic, clinical history, and laboratory test results data were collected using structured questionnaires. The collected data were entered into Epi-data 3.1 version and exported to SPSS-25 for analysis. Chi-square, independent sample t-test, and receiver operator characteristics curve of curve were used for analysis. A P-value of less than 0.05 was considered statistically significant.

RESULTS

In this study, significant increases were observed in the following values in the case group compared to the control group: In white blood cell (WBC) count, neutrophils, monocyte, mean platelet volume (MPV), neutrophils to lymphocyte ratio, monocyte to lymphocyte ratio (MLR), red blood cell width to platelet count ratio (RPR), red blood width coefficient variation, MPV to RPR, and platelet to lymphocyte ratio. Regarding MLR, a cut-off value of ≥ 0.26 was found, with a sensitivity of 68%, a specificity of 95%, a positive predictive value (PPV) of 93.2%, and a negative predictive value (NPV) of 74.8%. The area under the curve (AUC) was 0.828 (P < 0.001). For WBC, a cut-off value of ≥ 11.42 was identified, with a sensitivity of 55%, a specificity of 89%, a PPV of 83.3%, and a NPV of 66.4%. The AUC was 0.81 (P < 0.001). Neutrophils had a sensitivity of 67%, a specificity of 81%, a PPV of 77.9%, and a NPV of 71.1%. The AUC was 0.801, with a cut-off value of ≥ 6.76 (P = 0.001). These results indicate that they were excellent predictors of neonatal sepsis diagnosis.

CONCLUSION

The findings of our study suggest that certain hematological parameters and hemogram-derived markers may have a potential role in the diagnosis of neonatal sepsis.

Meta-analysis of the role of neutrophil to lymphocyte ratio in neonatal sepsis

INTRODUCTION

The neutrophil to lymphocyte ratio (NLR), an inflammatory biomarker, measures innate-adaptive immune system balance. In this systematic review and meta-analysis, we aim to analyze the current literature to evaluate the diagnostic role of NLR in neonatal sepsis.

METHODS

PubMed, Web of Science, and Scopus were used to conduct a systematic search for relevant publications published before May 14, 2022.

RESULTS

Thirty studies, including 2328 neonates with sepsis and 1800 neonates in the control group, were included in our meta-analysis. The results indicated that NLR is higher in neonates with sepsis compared to healthy controls (SMD = 1.81, 95% CI = 1.14-2.48, P-value < 0.001) in either prospective (SMD = 2.38, 95% CI = 1.40-3.35, P-value < 0.001) or retrospective studies (SMD = 0.87, 95% CI = 0.63-1.12, P-value < 0.001) with a pooled sensitivity of 79% (95% CI = 62-90%), and a pooled specificity of 91% (95% CI = 73-97%). Also, we found that NLR is higher in neonates with sepsis compared to those who were suspected of sepsis but eventually had negative blood cultures (SMD =1.99, 95% CI = 0.76-3.22, P-value = 0.002) with a pooled sensitivity of 0.79% (95% CI = 0.69-0.86%), and a pooled specificity of 73% (95% CI = 54-85%). In addition, neonates with sepsis had elevated levels of NLR compared to other ICU admitted neonates (SMD = 0.73, 95% CI = 0.63-0.84, P < 0.001). The pooled sensitivity was 0.65 (95% CI, 0.55-0.80), and the pooled specificity was 0.80 (95% CI, 0.68-0.88).

CONCLUSION

Our findings support NLR as a promising biomarker that can be readily integrated into clinical settings to aid in diagnosing neonatal sepsis. As evidenced by our results, restoring balance to the innate and adaptive immune system may serve as attractive therapeutic targets. Theoretically, a reduction in NLR values could be used to measure therapeutic efficacy, reflecting the restoration of balance within these systems.

The Neutrophil-to-Lymphocyte Ratio (NLR) Can Predict Sepsis's Presence and Severity in Malnourished Infants-A Single Center Experience

Sepsis represents one of the leading causes of death in newborns and infants, and prompt diagnosis is essential for achieving favorable outcomes. Regarding malnourished children with concurrent infection, most studies have focused, besides blood culture, on C-reactive protein and procalcitonin. Because malnutrition has a deleterious effect on cellular immune competence, the present study characterized the acute-phase response, including hematological indices, in response to sepsis. Among the examined laboratory biomarkers, procalcitonin and neutrophil-to-lymphocyte ratio were the most accurate discriminators between sepsis patients and those with bacterial infection. Moreover, these two parameters showed a gradual increase between sepsis, severe sepsis, and septic shock patients (p < 0.001). Subgroup analysis of the sepsis group revealed positive correlations of NLR with prolonged ICU stay (<0.001), acute organ dysfunction (0.038), mechanical ventilation (<0.001), and fatality (<0.001). In summary, our results suggest that the neutrophil-to-lymphocyte ratio can be used as an auxiliary diagnostic index in discriminating the presence and severity of bacterial sepsis in malnourished infants.

Comparison of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for the diagnosis of neonatal sepsis: a systematic review and meta-analysis

PURPOSE

To compare the performance of Neutrophil-to-Lymphocyte Ratio (NLR) with that of Platelet-to-Lymphocyte Ratio (PLR) in diagnosing neonatal sepsis (NS).

METHODS

PubMed and Embase were searched for relevant studies from the inception of the databases to May, 2022. The pooled sensitivity (SEN), specificity (SPE), and area under the receiver operator characteristic curve (AUC) were measured.

RESULTS

Thirteen studies involving 2610 participants were included. The SEN, SPE, and AUC of NLR were 0.76 (95%CI: 0.61-0.87), 0.82 (95%CI: 0.68-0.91), and 0.86 (95%CI: 0.83-0.89), respectively, and those of PLR were 0.82 (95%CI: 0.63-0.92), 0.80 (95%CI: 0.24-0.98), and 0.87 (95%CI: 0.83-0.89), respectively. Significant heterogeneity was observed among the studies. Subgroup analysis and meta-regression showed that types of sepsis (p = 0.01 for SEN), gold standard (p = 0.03 for SPE), and pre-set threshold (p<0.05 for SPE) might be the sources of heterogeneity for NLR, whereas the pre-set threshold (p<0.05 for SPE) might be the source of heterogeneity for PLR.

CONCLUSIONS

NLR and PLR would be of great accuracy for the diagnosis of NS, and the two indicators have similar diagnostic performance. However, the overall risk of bias was high, and significant heterogeneity was identified among the included studies. The results of this study should be interpreted prudently, and the normal or cut-off values and the type of sepsis should be considered. More prospective studies are needed to further support the clinical application of these findings.

Evaluation of Haematological Parameters and Uric Acid in the Diagnosis of Late Onset Neonatal Sepsis

Introduction A number of parameters studied in a whole blood count can be helpful in the diagnosis of neonatal sepsis. The platelet/lymphocyte ratio (PLR) is a systemic inflammatory marker in early sepsis and has been used as a diagnostic indicator in cardiovascular events and cancer. Being one of the major antioxidants in human biological fluids, serum uric acid is responsible for neutralising free radicals. The red cell distribution width/platelet ratio (RPR) is a diagnostic marker in adult inflammatory diseases. The objective of our study is to investigate the relationship of late neonatal sepsis with whole blood count parameters and serum uric acid levels. Materials and methods Newborns older than postnatal three days who had clinical and laboratory findings of sepsis were included in the study. The study included 140 newborns who were divided into three groups, 53 in the culture-proven late sepsis group, 47 in the clinical sepsis group, and 40 in the healthy control group. The whole blood count parameters and serum uric acid levels were examined in both the clinical sepsis and proven sepsis patients at the time when they were diagnosed with sepsis. Results The birth week was significantly lower in the evidenced and clinical sepsis patients compared to the healthy control group. Development of late sepsis was significantly higher in the male gender than in healthy controls. Serum uric acid levels were significantly higher in proven or clinical sepsis than in healthy controls. The level of serum uric acid (3.77±1.6) in proven sepsis was significantly higher than the control group (2.83±1.1). The uric acid level had an area under the curve (AUC) 0.552-0.717, 35% sensitivity, 95% specificity, 94.6% positive predictive value (PPV), and 36.9% negative predictive value (NPV) in the diagnosis of proven and clinical late sepsis. Neutrophil/lymphocyte ratio (NLR) was significantly higher in proven sepsis than in healthy newborns and was higher in the clinical sepsis group than in the proven sepsis group (p: 0.002). While the mean eosinophil value was 618.5±472.1 in proven sepsis, it was 549.3±294.9 in the control group and there was a statistically significant difference between the two groups (p: 0.036). Conclusion In late-onset neonatal sepsis, the NLR level was higher, and the eosinophil level was lower in the clinical sepsis patients than in healthy newborns. We believe that a higher level of serum uric acid in sepsis is effective in the early diagnosis of patients who also had other clinical findings of sepsis.

A machine learning approach using endpoint adjudication committee labels for the identification of sepsis predictors at the emergency department

Accurate sepsis diagnosis is paramount for treatment decisions, especially at the emergency department (ED). To improve diagnosis, clinical decision support (CDS) tools are being developed with machine learning (ML) algorithms, using a wide range of variable groups. ML models can find patterns in Electronic Health Record (EHR) data that are unseen by the human eye. A prerequisite for a good model is the use of high-quality labels. Sepsis gold-standard labels are hard to define due to a lack of reliable diagnostic tools for sepsis at the ED. Therefore, standard clinical tools, such as clinical prediction scores (e.g. modified early warning score and quick sequential organ failure assessment), and claims-based methods (e.g. ICD-10) are used to generate suboptimal labels. As a consequence, models trained with these "silver" labels result in ill-trained models. In this study, we trained ML models for sepsis diagnosis at the ED with labels of 375 ED visits assigned by an endpoint adjudication committee (EAC) that consisted of 18 independent experts. Our objective was to evaluate which routinely measured variables show diagnostic value for sepsis. We performed univariate testing and trained multiple ML models with 95 routinely measured variables of three variable groups; demographic and vital, laboratory and advanced haematological variables. Apart from known diagnostic variables, we identified added diagnostic value for less conventional variables such as eosinophil count and platelet distribution width. In this explorative study, we show that the use of an EAC together with ML can identify new targets for future sepsis diagnosis research.

Accuracy of the neutrophil-to-lymphocyte ratio for the diagnosis of neonatal sepsis: a systematic review and meta-analysis

OBJECTIVES

The purpose of this study was systematically and quantitatively to assess the value of the neutrophil-to-lymphocyte ratio (NLR) for the diagnosis of neonatal sepsis by systematic review and meta-analysis.

DESIGN

Systematic review and meta-analysis.

METHODS

Eight major databases, including The Cochrane, PubMed, Embase, Web of Science, CNKI, Wanfang, China Biomedical Literature Database and VIP Database, were systematically searched for NLR diagnoses of neonatal sepsis from inception to June 2022. Two investigators independently conducted the literature search, screening, data extraction and quality evaluation with the Quality Assessment of Diagnostic Accuracy Studies-2 checklist. Statistical analysis was performed using Review Manager V.5.3, Stata V.16.0, R (V.3.6.0) and Meta-DISC V.1.4.

RESULTS

A total of 14 studies comprising 1499 newborns were included in this meta-analysis. With a cut-off value ranging from 0.1 to 9.4, the pooled sensitivity of the NLR in the diagnosis of neonatal sepsis was 0.74 (95% CI: 0.61 to 0.83), the pooled specificity was 0.88 (95% CI: 0.73 to 0.95), the positive likelihood ratio (LR+) was 6.35 (95% CI: 2.6 to 15.47), the negative likelihood ratio (LR-) was 0.30 (95% CI: 0.19 to 0.46), the diagnostic OR (DOR) was 12.88 (95% CI: 4.47 to 37.08), area under the curve (AUC) was 0.87 (95% CI: 0.84 to 0.89). In the subgroup analysis of early-onset neonatal sepsis, the pooled sensitivity was 0.75 (95% CI: 0.47 to 0.91), the pooled specificity was 0.99 (95% CI: 0.88 to 1.00), the LR+ was 63.3 (95% CI: 5.7 to 696.8), the LR- was 0.26 (95% CI: 0.10 to 0.63), the DOR was 247 (95% CI: 16 to 3785) and the AUC was 0.97 (95% CI: 0.95 to 0.98).

CONCLUSIONS

Our findings suggest that the NLR is a helpful indicator for the diagnosis of early neonatal sepsis, but it still needs to be combined with other laboratory tests and specific clinical manifestations.

Eosinophil Cell Count Predicts Mortality in the Intensive Care Unit after Return of Spontaneous Circulation

BACKGROUND

Eosinophils constitute 1%-5% of peripheral blood leukocytes, less in the presence of acute infections (referred to as eosinopenia). Studies indicate that eosinopenia can be used as a prognostic predictor for chronic obstructive pulmonary disease exacerbation, sepsis, or acute myocardial infarction disease. There are only a few studies about predicting mortality in emergency departments and intensive care units (ICUs). Prognostic studies about patients in ICUs are generally carried out using different scoring systems. We aimed to analyze if the eosinophil count can estimate the prognosis among non-traumatic patients who underwent cardiopulmonary resuscitation and were hospitalized in ICU thereafter.

METHODS

The data were evaluated of 865 non-traumatic adult patients (>18 years of age) who were admitted with cardiopulmonary arrest or developed cardiopulmonary arrest during clinical follow-ups. Admission venous blood sample tests, complete blood count, and biochemical laboratory results were recorded. Arterial blood gas results were also evaluated. The mean results of the recorded laboratory results were compared between the surviving and non-surviving patients groups.

RESULTS

There was a significant difference between the two groups in regard to platelet, eosinophil count, pH, PaO₂, SaO₂, and HCO₃^- (P<0.001 for all). In the multiple linear regression analysis, eosinophil counts were found to be an independent factor (odds ratio=0.03, 95% confidence interval 0.33-0.56, P<0.001) associated with the mortality after cardiopulmonary resuscitation.

CONCLUSION

Because admission eosinophil counts can be measured easily, they are inexpensive biomarkers that can be used for predicting the prognosis among the patients who have return of spontaneous circulation and are treated in ICUs.

Current-proven neonatal sepsis in Indonesian tertiary neonatal intensive care unit: a hematological and microbiological profile

Background and Objectives:

Neonatal sepsis is the third leading cause of neonatal death in the world. The patterns of pathogens causing neonatal sepsis varies in many countries. This study was aimed to identify hematological and microbiological profile of culture-proven neonatal sepsis in Indonesian tertiary neonatal intensive care unit (NICU).

Materials and Methods:

Hospital based cross-sectional study was conducted in all inborn neonates that were suspected sepsis neonatal over a period of six months from April to September 2019. Complete blood count, c-reactive protein (CRP) and blood culture were examined before antibiotic administration. Statistical analysis were calculated based on Chi-Square’s Test and Mann-Whitney U test and p <0.05 considered significant.

Results:

One hundred four inborn neonates admitted to NICU and diagnosed with suspected neonatal sepsis were recruited. Culture-proven neonatal sepsis were confirmed in 52 (50%) neonates, 13 (25%) in early-onset neonatal sepsis (EONS) and 39 (75%) in late-onset neonatal sepsis (LONS). The most common abnormal hematological profile were anemia and thrombocytopenia, with amount of 61.5% and 75%, respectively. High CRP only detected in 36.4% and only 18.5% experienced leukopenia. Gram negative bacteria responsible in 75% from total isolated pathogens. Klebsiella pneumoniae accounted for 48.1% followed by coagulase negative staphylococci (CONS) for 17.3% and Enterobacter cloacae for 11.5%.

Conclusion:

Anemia and thrombocytopenia were the top two hematological profile of culture-proven neonatal sepsis. Most causes of culture-proven neonatal sepsis were Gram negative bacteria and the dominant pathogen was K. pneumoniae.

Shared and unique individual risk factors and clinical biomarkers in children with allergic rhinitis and obstructive sleep apnea syndrome

INTRODUCTION

Rhinitis and obstructive sleep apnea syndrome (OSAS) are different diseases, but have some similar risk factors.

OBJECTIVE

The aims of this study were to compare the risk factors and clinical biomarkers for rhinitis and OSAS in children.

METHODS

We examined 3917 children (age 4-13 years) who were enrolled in a cross-sectional study conducted in Seongnam, Korea. Their parents completed the Pediatric Sleep Questionnaire (PSQ) for evaluation of OSAS and the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire for evaluation of rhinitis. Clinical biomarkers, including total eosinophil count and neutrophil-lymphocyte ratio (NLR), were measured in a subset of these children.

RESULTS

OSAS and rhinitis had prevalences of 4.0% and 43.5%, respectively. Body mass index (P < 0.001) and prematurity (P = 0.016) were significantly associated with OSAS, but not with rhinitis. Higher parental education and income increased the risk for rhinitis, but decreased the risk for OSAS. Having more siblings and birth by Cesarean delivery decreased the risk for rhinitis, but living in a new household increased the risk for rhinitis. A short distance of the residence to a main road during pregnancy significantly increased the risk of OSAS. Males, increased exposure to mould, and firstborns had increased risk of OSAS and rhinitis. The NLR was higher in OSAS patients than in those with allergic rhinitis (P = 0.001).

CONCLUSION

OSAS and rhinitis shared some risk factors, whereas other factors had inverse association with the two disorders. These results imply that different strategies might be used for prevention of rhinitis and OSAS.

Eosinopenia as a marker of diagnosis and prognostic to distinguish bacterial from aseptic meningitis in pediatrics

Procalcitonin (PCT) has proven its efficacy to distinguish bacterial from aseptic meningitis in children. Nevertheless, its use in routine is limited by its cost and availability, especially in low- and middle-income countries. It is now acknowledged that eosinopenia is a marker of infection and/or severity of the systemic inflammatory response. Although no study ever demonstrated that eosinopenia could differentiate bacterial from viral infection, we decided to conduct a study concerning meningitis in children. This bicentric and retrospective study was conducted between January 2012 and October 2018, in children hospitalized for meningitis. The white blood cell was systematically gathered at the admission to evaluate the eosinophil count. Characteristic data were compared between 2 groups: documented bacterial meningitis (DBP) and aseptic meningitis which includes documented viral meningitis (DVM) and non-documented meningitis (ND). Among 190 patients admitted for meningitis, 151 were analyzed, including DBM (n = 45), DVM (n = 73), and ND (n = 33) meningitis. Groups were comparable. Mean age was 33 ± 48 months with a sex ratio of 1.6. Mean of eosinophil count was 15 ± 34/mm³ in the DBM group versus 132 ± 167/mm³ for the aseptic meningitis group (p < 0.0001). Best threshold for the diagnosis of bacterial meningitis was an eosinophil count < 5/mm³ with a sensitivity of 80% and specificity of 73% and a likelihood ratio of 2.9. Eosinopenia seems to be a reliable and non-invasive marker of bacterial meningitis in pediatrics. The absence of extra cost makes it very interesting in low- and middle-income countries or when usual biomarkers such as PCT are unavailable.