Diagnostic Accuracy and Prognostic Value of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Septic Patients outside the Intensive Care Unit

Correlation between neutrophil to lymphocyte ratio and C-reactive protein in diverse disease states in hospitalized patients

Objectives

This study aims to find if any significant correlation exists between C-reactive protein and Neutrophil to Lymphocyte Ratio as an indirect measure of inflammation.

Methods

We selected 983 patients with any inflammatory condition who presented to a tertiary care hospital and were admitted in medical wards or Intensive Care Units (ICUs) of KRL Hospital Islamabad from December 2021 to December 2022. The study was a cross sectional study and convenience sampling was done. The patients were categorized into five groups depending upon their pathophysiology. Kolmogorov Smirnov test was used to assess the normality of the data, and Spearman's coefficient was used to calculate the correlation between NLR and CRP.

Results

A total of 983 patients were included. Mean CRP and NLR levels were 89.9±3.2 and 7.06±0.24, respectively. There was a significant positive correlation between CRP-NLR in the infectious, non-infectious non-inflammatory, and malignancy groups (0.420, 0.381, 0.642, p <0.01), and inflammatory group (0.322, p <0.05), and no correlation with chronic diseases.

Conclusion

A significant correlation was shown to exist between CRP and NLR in patients with malignancies, non-infective non-inflammatory, inflammatory, and infective conditions and can therefore be used interchangeably to detect the presence of inflammation. Further exploration of these associations may contribute to a more nuanced understanding of the intricate relationships between different markers of inflammation and response to treatment.

Are the Hematological Parameters Useful in Differentiating Acute Pyelonephritis from Cystitis in Patients with Chronic Kidney Disease?

BACKGROUND AND OBJECTIVES

The importance of hematological parameters has started to be explored with increased interest in many fields lately, with different studies finding an association between those parameters and inflammatory status, atherosclerosis, comorbidities, malnutrition, neoplasia and even a faster progression of chronic kidney disease (CKD). On the other hand, CKD itself presents as an inflammatory condition, in which a lot of pathways are modified and the response to an infectious agent could be less than expected. Regarding the latter aspect, in this study we aim to explore the differences between the hematologic response during a lower versus upper urinary tract infection in patients with CKD.

MATERIALS AND METHODS

We analyzed 70 patients with chronic kidney disease and either cystitis or pyelonephritis considering the hematologic parameters, the classical inflammatory ones as well as the etiology of CKD.

RESULTS

Neutrophils, neutrophils/lymphocytes ratio (NLR), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and fibrinogen were higher in patients with pyelonephritis (PNA), while albumin was significantly lower. In a binary logistic regression model that explained 80.2% of the variability of PNA diagnosis and correctly predicted it in 92.9% of cases, NLR, CRP and fibrinogen were the independent predictors.

CONCLUSIONS

Hematologic parameters can serve not only as an indicator of the inflammatory status, but also as a laboratory biomarker for PNA in patients with CKD.

Neutrophil-to-lymphocyte ratio and red blood cell distribution width to platelet ratio and their relationships with inflammatory and antioxidant status in dogs with different stages of heart failure due to myxomatous mitral valve disease

We aimed to evaluate the red blood cell distribution width-to-platelet ratio (RDW/PLT) with other complete blood cell count (CBC) indices and their correlations with serum proinflammatory cytokines, acute phase proteins (APPs), and antioxidant biomarkers in dogs at different stages of heart failure (HF). A total of 29 dogs were divided into four groups according to the ACVIM Consensus Statement: stage-A (healthy/controls, n = 8), stage-B2 (n = 6), stage-C (n = 10), and stage-D (n = 5). Seventeen CBC indices were calculated and correlated with the measurements of inflammatory, APPs, and antioxidant biomarkers, as well as selected echocardiographic variables in all dogs. At stage-C, CBC indices were evaluated 14 days after the treatment. Statistically significant changes were observed only for RDW/PLT and neutrophil-to-lymphocyte ratio (NLR) between groups. NLR increased, but RDW/PLT deceased in dogs with HF, compared to controls (P < 0.05). There were no statistically differences between pre- and post-treatment CBC indices. There were significantly positive and negative correlations between the CBC indices, serum parameters and selected echocardiographic variables in dogs with HF(P < 0.05). ROC analysis showed the best sensitivity (57% and 68%) and specificity (100% and 57%) for NLR > 5.8 and RDW/PLT ≤ 0.057 for predicting the severity of HF, respectively. Results showed that NLR and RDW/PLT may have potential for monitoring severity of the disease and the effect of treatment in dogs with HF. Imbalances between indices of circulating blood cells can contribute to immunoinflammatory and antioxidant responses in pathogenesis of canine HF, which may provide us alternative targets to develop new diagnostic and therapeutic strategies in veterinary medicine.

Neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, platelet-to-lymphocyte ratio associated with 28-day all-cause mortality in septic patients with coronary artery disease: a retrospective analysis of MIMIC-IV database

BACKGROUND

High Neutrophil-to-Lymphocyte Ratio (NLR), Monocyte-to-Lymphocyte Ratio (MLR), Platelet-to-Lymphocyte Ratio (PLR) were associated with worse prognosis of patients with sepsis. In-hospital mortality has been reported to be higher in patients with coronary artery disease (CAD) and sepsis than those with sepsis alone. However, the relationship between NLR, MLR, PLR and mortality in septic patients with coronary artery disease (CAD) remains unclear. The study aimed to explore the association between NLR, MLR, PLR and 28-day all-cause mortality in septic patients with CAD.

METHODS

We performed an observational cohort study of septic patients with CAD from the Medical Information Mart for Intensive Care (MIMIC)-IV database between 2008 and 2019. The patients were categorized by three group (Q1: low levels, Q2: medium levels, Q3: high levels) based on tertiles of NLR, MLR, and PLR. The associations between NLR, MLR, PLR and 28-day all-cause mortality were examined using the Cox proportional hazards model. Subsequently, we applied receiver operating characteristic (ROC) analysis for predicting 28-day mortality in septic patients with CAD by combining NLR, MLR and PLR with the modified sequential organ failure assessment (mSOFA) scores.

RESULTS

Overall 1,175 septic patients with CAD were included in the study. Observed all-cause mortality rates in 28 days were 27.1%. Multivariate Cox proportional hazards regression analysis results showed that 28-day all-cause mortality of septic patients with CAD was significantly related to rising NLR levels (adjusted hazard ratio [aHR]: 1.02; 95% confidence interval [CI]: 1.01-1.02; P < 0.001), MLR levels (aHR: 1.29; 95%CI: 1.18-1.41; P < 0.001), and PLR levels (aHR: 1.0007; 95%CI: 1.0004-1.0011; P < 0.001). Meanwhile, the higher levels (Q3) group of NLR, MLR, and PLR also had a higher risk of 28-day all-cause mortality than the lower (Q1) group. The area under the ROC curve of NLR, MLR, PLR, and mSOFA score were 0.630 (95%CI 0.595-0.665), 0.611 (95%CI 0.576-0.646), 0.601 (95%CI 0.567-0.636) and 0.718 (95%CI 0.689-0.748), respectively. Combining NLR, MLR, and PLR with mSOFA scores may improve ability of predicting 28-day mortality (AUC: 0.737, 95%CI 0.709-0.766).

CONCLUSION

Higher levels of NLR, MLR and PLR were associated with 28-day all-cause mortality in septic patients with CAD. Further investigation will be needed to improve understanding of the pathophysiology of this relationship.

Examining the relationship between alterations in plasma cholesterol, vascular endothelin-1 levels, and the severity of sepsis in children: An observational study

Considering the significant impact of total cholesterol (TC) and vascular endothelin-1 (ET-1) on children sepsis outcomes, this research aimed to explore the association between the levels of plasma cholesterol and vascular endothelin-1 and the severity of sepsis and evaluated its clinical implications. In this study, we examined 250 pediatric patients diagnosed with sepsis between February 2019 and April 2021, collecting data on their plasma levels of TC and ET-1. Depending on the observed outcomes, the participants were divided into 2 categories: a group with a positive prognosis (control group, n = 100) and a group with a negative prognosis (n = 50). We assessed the significance of plasma TC and ET-1 levels in forecasting the outcomes for these pediatric patients. Patients in the group with a poor prognosis experienced notably longer hospital stays and higher treatment expenses than those in the control group (P < .05). Within the first 24 hours of admission and again on days 3 and 7, the levels of ET-1 were significantly higher in the poor prognosis group, whereas plasma TC levels were notably lower in comparison to the control group (P < .05). A Spearman correlation analysis identified a significant correlation between the levels of plasma TC and ET-1 and the severity of sepsis among the children (P < .05). The diagnostic performance for the severity of sepsis in children, as measured by the area under the curve (AUC), was 0.805 for plasma TC, 0.777 for ET-1 levels, and 0.938 when both were combined. This investigation underscores a meaningful relationship between the levels of plasma TC and ET-1 in pediatric sepsis patients, suggesting these biomarkers are highly valuable in predicting patient outcomes. High levels of ET-1 and low levels of TC in these patients signify a grave condition and a poor prognosis.

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.

Diagnostic accuracy of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and neutrophil-lymphocyte-to-platelet ratio biomarkers in predicting bacteremia and sepsis in immunosuppressive patients with cancer: literature review

Background

This literature review explores the role of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and neutrophil-lymphocyte-to-platelet ratio (NLPR) biomarkers, as potential indicators for predicting bacteremia and sepsis in patients with cancer.

Objective

Tracing the evolution of interest in this area since 2001, the aim of this review was to report a comprehensive overview of current knowledge and gaps, particularly in patients undergoing immunosuppression.

Summary of Findings

The literature research indicates the potential of NLR, PLR, and other biomarkers in diagnosing and predicting sepsis, with some studies emphasizing their value in mortality prediction. A specific focus on bacteremia shows the effectiveness of NLR and PLR as early indicators and prognostic tools, though mostly in noncancer patient populations. While NLR and PLR are promising in general cancer patient populations, the review addresses the challenges in applying these biomarkers to patients with neutropenic and lymphopenic cancer. The NLPR could be considered a significant biomarker for inflammation and mortality risk in various medical conditions, yet its diagnostic accuracy in patients with immunosuppressed cancer is not extensively validated.

Conclusion

This review offers a snapshot of the current research on biomarkers in patients with immunocompromised cancer in the sepsis and bacteremia area. More focused research on their application is necessary. This gap underscores an opportunity for future studies to enhance diagnostic and prognostic capabilities in this high-risk group.

Clinical image of sepsis-associated encephalopathy midst E. coli urosepsis: Emergency department database study

Background

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, which, if untreated, leads to multi-organ failure. One of the severe possible complications is sepsis associated encephalopathy (SAE), a neurological dysfunction occurring secondary to a severe inflammatory response. It manifests as acute cognitive dysfunction and sudden-onset dysfunctions in mental state. Uropathogenic Escherichia coli is the most common pathogen causing bacteremia, responsible for 80% of uncomplicated outpatient urinary tract infections and 40% of nosocomial infections. The study aimed to assess the difference in the severity and the course of urosepsis caused by E. coli in patients with and without septic encephalopathy.

Materials and methods

This study presents a retrospective analysis of the population of urosepsis patients admitted to the Emergency Department between September 2019 and June 2022. Inflammatory parameters, urinalysis and blood cultures were performed, along with a clinical evaluation of sepsis severity and encephalopathy. The patients were then stratified into SAE and non-SAE groups based on neurological manifestations and compared according to the collected data.

Results

A total of 199 septic patients were included in the study. E. coli-induced urosepsis was diagnosed in 84 patients. In this group, SAE was diagnosed in 31 (36.9%) patients (33.3% in males, 40.5% females). Patients with SAE were found to be hypotensive (p < 0,005), with a higher respiratory rate (p < 0,017) resulting in a higher mortality rate (p = 0.002) compared to non-SAE septic patients. The APACHE II score was an independent risk factor associated with a higher mortality rate. Biochemical parameters between the groups did not show any statistical importance related to the severity of urosepsis.

Conclusions

The severity of urosepsis and risk of SAE development increase according to the clinical condition and underlying comorbidities. Urosepsis patients with SAE are at a higher risk of death. Patients should undergo more careful screening for the presence of SAE on admission, and more intense monitoring and treatment should be provided for patients with SAE. This study indicates the need to develop projects aiming to further investigate neuroprotective interventions in sepsis.

Prognostic Nutritional Index Enhances the Discriminatory Ability of Procalcitonin for Predicting Pediatric Sepsis

Objective. Improving diagnostic ability of pediatric sepsis is of great significance for reducing the mortality of sepsis. This study explored the discriminatory capacity of nutritional index (PNI) in pediatric sepsis. Methods. We retrospectively enrolled 134 children with suspected sepsis and collected their clinical and laboratory data. Receiver operating characteristic curves (ROC), decision curve analysis (DCA) and net reclassification improvement (NRI) were performed to compare the predictive significance of the PNI, procalcitonin (PCT) and their combination. Results. Among 134 patients, 65 children were diagnosed with sepsis and 69 children with non-sepsis. PCT and PNI were independently associated with pediatric sepsis. PCT was superior to PNI to predict pediatric sepsis. The model based on PCT + PNI improved the predictive capacity than them alone, as demonstrated by ROC, DCA and NRI, respectively. Conclusion. PNI was independently associated with pediatric sepsis, and addition of PNI could improve the capacity of PCT to predict pediatric sepsis.

Neutrophil to lymphocyte ratio in odontogenic infection: a systematic review

BACKGROUND

We conducted this systematic review to compile the evidence for the role of neutrophil to lymphocyte ratio (NLR) in odontogenic infection (OI) and to determine whether NLR is elevated in patients with OI. This was done to aid physicians in better understanding this condition for clinical management.

METHODS

The search was conducted on PubMed, Scopus, and Web of Science libraries on March 30, 2023. Two reviewers independently screened the studies using Endnote software. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the studies.

RESULTS

A total of nine studies were included in the review. Among patients with OI, positive and statistically significant correlations of NLR were seen with more severe disease, a prolonged hospital stay, postoperative requirement of antibiotics, and total antibiotic dose needed. In the receiver operating characteristics (ROC) analysis, the optimum cut-off level of NLR was 5.19 (specificity: 81, sensitivity: 51). In addition, NLR was correlated with preoperative fever (p = 0.001). Among patients with Ludwig's Angina, NLR could predict disease severity and length of stay in the hospital (p = 0.032 and p = 0.033, respectively). In addition, the relationship between the NLR and mortality was statistically significant (p = 0.026, specificity of 55.5%, and sensitivity of 70.8%). Among patients with severe oral and maxillofacial space infection, a positive correlation was found between IL-6 and CRP with NLR (rs = 0.773, P = 0.005 and rs = 0.556, P = 0.020, respectively). Also, a higher NLR was considered an essential predictor of organ involvement (P = 0.027) and the number of complications (P = 0.001). However, among diabetes mellitus (DM) patients afflicted with submandibular abscesses, NLR had no association with therapeutic response.

CONCLUSIONS

Many people around the world suffer from OI, and a cheap and fast biomarker is needed for it. Interestingly, inflammation plays a role in this infection, and elevated NLR levels can be a good biomarker of inflammation and, as a result, for OI progression.

Predictive value of the neutrophil-to-lymphocyte ratio in the prognosis and risk of death for adult sepsis patients: a meta-analysis

Background

The neutrophil-to-lymphocyte ratio (NLR) is a commonly used biomarker for acute inflammation that often rises during sepsis, making it a valuable diagnostic indicator for clinical practice. However, no consensus has been reached on the prognostic value of NLR for predicting the prognosis and mortality risk in adult sepsis patients. In light of this controversy, we conducted a meta-analysis to clarify the prognostic significance of NLR in adult sepsis patients. The meta-analysis was registered in the PROSPERO database (registration number CRD42023433143).

Methods

We performed a comprehensive literature search in PubMed, Cochrane Library, Ovid, and Springer databases, using retrieval terms "sepsis" or "septic shock" and "prognosis" or "mortality" for studies published between January 1, 2000, and May 31, 2023. Children and neonates with sepsis were excluded from our research. Two independent researchers conducted the literature search and data extraction. Consensus was reached when discrepancies occurred, and in case of persistent discrepancies, the final decision was made by the research supervisor. The hazard ratio (HR) and its corresponding 95% confidence interval (95% CI) were extracted from each study included in the analysis. A random-effects model was used to synthesize all HRs and their 95% CIs. Sensitivity analysis was performed to investigate heterogeneity. Sensitivity analysis was conducted to identify studies that had a significant impact on the overall results of the meta-analysis. Subgroup analysis and meta-regression were performed to explore sources of heterogeneity. Egger's test was also used to investigate publication bias in this meta-analysis.

Results

After a comprehensive literature search and screening, we included 12 studies comprising 10,811 patients for the meta-analysis. The pooled results indicated that patients with a higher NLR level were associated with a poor prognosis (Random-effects model, HR: 1.6273, 95% CI: 1.3951-1.8981). Heterogeneity testing showed significant heterogeneity (I2 = 87.2%, 95% CI: 79.5-92, p<0.0001). Sensitivity analysis was performed to investigate the sources of heterogeneity, which revealed that the omission of one highly sensitive study significantly reduced the I2 value. After removing this study, a strong association was found between a higher NLR level and poor prognosis and risk of death in adult sepsis patients (Random-effects model, HR: 1.6884, 95% CI: 1.4338-1.9882). Both subgroup analysis and meta-regression indicated that the study design and testing time of NLR were sources of heterogeneity. Egger's test showed no obvious publication bias in this meta-analysis.

Conclusion

NLR is a reliable and valuable biomarker for predicting prognosis and the risk of death in adult sepsis patients.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023433143] PROSPERO, identifier [CRD42023433143].

Effect of neutrophil to lymphocyte ratio on prognosis of elderly patients with severe sepsis combined with diabetes mellitus

BACKGROUND

To investigate the predictive value of neutrophil-to-lymphocyte ratio (NLR) in the short-term prognosis of elderly patients with severe sepsis combined with diabetes mellitus (DM).

METHODS

The clinical data of 162 elderly patients with severe sepsis combined with DM from January 2018 to December 2022 were retrospectively collected. These patients were divided into a survival group (n = 104) and a death group (n = 58) according to 90-day prognosis. The number of neutrophils, lymphocytes, and NLR were compared. The optimal cut-off value for NLR to predict 90-day prognosis in elderly patients with severe sepsis combined with DM was determined using Receiver Operator Characteristic (ROC) curves, and the patients were divided into high and low NLR groups depending on the optimal cut-off value. The Kaplan-Meier method was used to plot the survival curves of the high and low NLR groups. Risk factors for the 90-day death in elderly patients with severe sepsis combined with DM were analyzed by a multivariate cox regression model.

RESULTS

There were no significant differences in gender, age, history of hypertension and hyperlipidemia, intensive care unit (ICU) stay, duration of mechanical ventilation, and oxygenation index between the survival group and death group (p > 0.05). However, acute physiological and chronic health evaluation II (APACHE II) scores, and sepsis-related organ failure assessment (SOFA) scores were significantly lower in the survival group compared with the death group (p < 0.05). In the survival group, neutrophils counts and NLR were much lower than those in the death group, while lymphocytes counts were much higher (p < 0.05). ROC curves showed that the optimal cut-off value for NLR to predict 90-day mortality in elderly patients with severe sepsis combined with DM was 3.482. Patients were divided into high NLR and low NLR groups based on whether NLR was ≥ 3.482. In terms of the log-rank test results, patients in the low NLR group had a significantly higher 90-day survival rate than those in the high NLR group (Logrank χ2 = 8.635, p = 0.003). The multivariate cox regression model showed that the length of ICU stay longer than 15 days and NLR ≥ 3.482 were independent risk factors for 90-day prognosis in elderly patients with severe sepsis combined with DM.

CONCLUSION

NLR ≥ 3.482 can be used to predict whether poor prognosis occurs in the short term after illness in elderly patients with severe sepsis combined with DM, and has good assessment value.

Mid-Regional Pro-Adrenomedullin Can Predict Organ Failure and Prognosis in Sepsis?

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ≥ 3.39 ng/mL identified acute kidney injury (AKI); ≥2.99 ng/mL acute respiratory distress syndrome (ARDS); ≥2.28 ng/mL acute heart failure (AHF); ≥2.55 ng/mL Glascow Coma Scale (GCS) < 15; ≥3.38 multi-organ involvement; ≥3.33 need for ICU transfer; ≥2.0 Sequential Organ Failure Assessment (SOFA) score ≥ 2; and ≥3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ≥ 2 ng/mL correlates with AKI, anemia and SOFA score ≥ 2, and MR-proADM ≥ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ≥ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ≥ 1.44 ng/mL identified patients with AKI; ≥1.0 ng/mL with AHF; and ≥1.44 ng/mL with anemia and SOFA score ≥ 2. In the multivariate analysis, MR-proADM ≥ 1.44 ng/mL correlated with AKI, anemia, SOFA score ≥ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

The Role of C-Reactive Protein and Neutrophil to Lymphocyte Ratio in Predicting the Severity of Odontogenic Infections in Adult Patients

Background and Objectives: Odontogenic infections (OI) represent a frequent cause of dental and maxillo-facial interventions, mostly due to late presentations or misdiagnosed complications. It is believed that the intensity of the immunoinflammatory response in OI is the main prognostic factor. Therefore, in this research, it was pursued to determine if the combination of C-reactive protein (CRP) and Neutrophil to Lymphocyte Ratio (NLR) (CRP-NLR) may serve as potential severity predictors in patients with odontogenic infections. Materials and Methods: A retrospective analysis on 108 patients hospitalized for odontogenic infections was conducted at the Department of Maxillofacial Surgery. Depending on the symptom severity scale, patients hospitalized with OI were divided into two equal groups based on infection severity (SS). Results: Patients with severe OI from Group B were associated more frequently with diabetes mellitus and smoking more often than those with a lower severity from Group A. In Group A, abscesses of odontogenic origin accounted for 70.4% of hospitalizations, while in Group B, abscesses and cellulitis were associated in 55.6% of cases (p-value < 0.001). The disease outcomes were more severe in Group B patients, where 22.2% of them developed sepsis, compared to 7.4% of Group A patients (p-value = 0.030). However, there was no significant difference in mortality rates. The SS and systemic immune inflammation index (SII) scores of Group B patients were substantially higher than Group A patients (13.6 vs. 6.1 for the SS score, p-value < 0.001), respectively, 2312.4 vs. 696.3 for the SII score (p-value < 0.001). All biomarker scores, including the CRP-NLR relationship, were considerably higher in Group B patients, with a median score of 341.4 vs. 79.0 in Group B (p-value < 0.001). The CRP-NLR association determined a 7.28-fold increased risk of severe OI. The receiver operating curve (ROC) analysis of CRP-NLR yielded an area under curve (AUC) value of 0.889, with high sensitivity (79.6%) and high specificity (85.1%), for predicting a severe odontogenic infection using biomarkers measured at hospital admission (p-value < 0.001). Conclusions: Therefore, it can be concluded that CRP-NLR is a reliable and affordable biomarker for determining the severity of odontogenic infections that may be included in other prognostic models for dental infections.

Synergistic effect of myocardial injury and mid-regional proAdrenomedullin elevation in determining clinical outcomes of SARS-CoV-2 patients

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is a systemic disease induced by SARS-CoV-2 causing myocardial injury. To date, there are few data on the correlation between mid-regional proAdrenomedullin (MR-proADM) and myocardial injury. The aim of this study was to evaluate whether the association of myocardial injury and elevated mid-regional proAdrenomedullin values could predict mortality of SARS-CoV-2 patients, to offer the best management to COVID-19 patients.

MATERIALS AND METHODS

All patients hospitalized for SARS-CoV-2 infection at the COVID-19 Center of the Campus Bio-Medico of Rome University were included between October 2020 and March 2021 and were retrospectively analyzed. Myocardial injury was defined as rising and/or fall of cardiac hs Troponin I values with at least one value above the 99th percentile of the upper reference limit (≥15.6 ng/L in women and ≥34.2 ng/L in men). The primary outcome was 30-day mortality. Secondary outcomes were the comparison of MR-proADM, CRP, ferritin, and PCT as diagnostic and prognostic biomarkers of myocardial injury. Additionally, we analyzed the development of ARDS, the need for ICU transfer, and length of stay (LOS).

RESULTS

A total of 161 patients were included in this study. Of these, 58 (36.0%) presented myocardial injury at admission. An MR-proADM value ≥ 1.19 nmol/L was defined as the optimal cut-off to identify patients with myocardial injury (sensitivity 81.0% and specificity 73.5%). A total of 121 patients (75.2%) developed ARDS, which was significantly more frequent among patients with myocardial injury (86.2 vs. 68.9%, p = 0.015). The overall 30-day mortality was 21%. Patients with myocardial injury presented significantly higher mortality compared to those without the same (46.6 vs. 6.8%, p < 0.001). When dividing the entire study population into four groups, based on the presence of myocardial injury and MR-proADM values, those patients with both myocardial injury and MR-proADM ≥ 1.19 nmol/L presented the highest mortality (53.2%, p < 0.001). The combination of myocardial injury and MR-proADM values ≥ 1.19 nmol/L was an independent predictor of death (OR = 7.82, 95% CI = 2.87-21.30; p < 0.001).

CONCLUSION

The study is focused on the correlation between myocardial injury and MR-proADM. Myocardial injury induced by SARS-CoV-2 is strongly associated with high MR-proADM values and mortality.

Association between glucose-to-lymphocyte ratio and in-hospital mortality in intensive care patients with sepsis: A retrospective observational study based on Medical Information Mart for Intensive Care IV

Background

This study aimed to evaluate the association between the glucose-to-lymphocyte ratio (GLR) and in-hospital mortality in intensive care unit (ICUs) patients with sepsis.

Methods

This is a retrospective cohort study. Patients with sepsis from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database had their baseline data and in-hospital prognosis retrieved. Multivariable Cox regression analyses were applied to calculate adjusted hazard ratios (HR) with 95% confidence intervals (CI). Survival curves were plotted, and subgroup analyses were stratified by relevant covariates. To address the non-linearity relationship, curve fitting and a threshold effect analysis were performed.

Results

Of the 23,901 patients, 10,118 patients with sepsis were included. The overall in-hospital mortality rate was 17.1% (1,726/10,118). Adjusted for confounding factors in the multivariable Cox regression analysis models, when GLR was used as a categorical variable, patients in the highest GLR quartile had increased in-hospital mortality compared to patients in the lowest GLR quartile (HR = 1.26, 95% CI: 1.15–1.38). When GLR was used as a continuous variable, each unit increase in GLR was associated with a 2% increase in the prevalence of in-hospital mortality (adjusted HR = 1.02, 95% CI: 1.01–1.03, p = 0.001). Stratified analyses indicated that the correlation between the GLR and in-hospital mortality was stable. The non-linear relationship between GLR and in-hospital mortality was explored in a dose-dependent manner. In-hospital mortality increased by 67% (aHR = 1.67, 95% CI: 1.45–1.92) for every unit GLR increase. When GLR was beyond 1.68, in-hospital mortality did not significantly change (aHR: 1.04, 95% CI: 0.92–1.18).

Conclusion

There is a non-linear relationship between GLR and in-hospital mortality in intensive care patients with sepsis. A higher GLR in ICU patients is associated with in-hospital mortality in the United States. However, further research is needed to confirm the findings.

A Predictive Model Based on Inflammatory and Coagulation Indicators for Sepsis-Induced Acute Kidney Injury

Background

Sepsis-induced acute kidney injury (S-AKI) is associated with systemic inflammatory responses and coagulation system dysfunction, and it is associated with an increased risk of mortality. However, there was no study to explore the predictive value of inflammatory and coagulation indicators for S-AKI.

Methods

In this retrospective study, 1051 sepsis patients were identified and divided into a training cohort (75%, n = 787) and a validation cohort (25%, n = 264) in chronological order according to the date they were admitted. Univariate analyses and multivariate logistic regression analyses were performed to identify the independent predictors of S-AKI. The logistic regression analyses (enter methods) were used to conducted the prediction models. The ROC curves were used to determine the predictive value of the constructed models on S-AKI. To test whether the increase in the AUC is significant, we used a two-sided test for ROC curves available online (http://vassarstats.net/roc_comp.html). The secondary outcome was different AKI stages and major adverse kidney events within 30 days (MAKE30). Stage 3B of S-AKI was defined as both meeting the stage 3 criteria [increase of Cr level by > 300% (≥ 4.0 mg/dL with an acute increase of ≥ 0.5 mg/dL) and/or UO < 0.3 mL/kg/h for > 24 h or anuria for > 12 h and/or acute kidney replacement therapy] and having cystatin C positive. MAKE30 were a composite of death, new renal replacement therapy (RRT), or persistent renal dysfunction (PRD).

Results

We discovered that cardiovascular disease, white blood cell (WBC), mean arterial pressure (MAP), platelet (PLT), serum procalcitonin (PCT), prothrombin time activity (PTA), and thrombin time (TT) were independent predictors for S-AKI. The predictive value (AUC = 0.855) of the simplest model 3 (constructed with PLT, PCT, and PTA), with a sensitivity of 77.6% and a specificity of 82.4%, had a similar predictive value comparing with the model 1 (AUC = 0.872) and the model 2 (AUC = 0.864) in the training cohort (P > 0.05). Compared with the model 1 (AUC = 0.888) and the model 2 (AUC = 0.887), the model 3 (AUC = 0.887) had a similar predictive value in the validation cohort. Moreover, model 3 had the best predictive power for predicting S-AKI in the stage 3 (AUC = 0.777), especially in stage 3B (AUC = 0.771). Finally, the model 3 (AUC = 0.843) had perfect predictive power for predicting MAKE30 in sepsis patients.

Conclusion

Within 24 hours after admission, the simplest model 3 (constructed with PLT, PCT, and PTA) might be a robust predictor of the S-AKI in sepsis patients, providing information for timely and efficient intervention.

Active Surveillance Cultures and Procalcitonin in Combination With Clinical Data to Guide Empirical Antimicrobial Therapy in Hospitalized Medical Patients With Sepsis

Objective

The prevalence of colonization with multidrug-resistant organisms (MDRO) has increased over the last decade, reaching levels as high as 23% in certain patient populations. Active surveillance cultures (ASC) represent a valuable tool to identify patients colonized with MDRO to apply preventive measures, reduce transmission, and guide empiric antimicrobial therapy. There is a paucity of data evaluating the impact of admission ASCs to predict future infection. The aim of this study was to evaluate the concordance between ASCs results and the development of clinical infection by the same microorganism identified in the surveillance swab ("swab-related infection"), in hospitalized septic patients, and to evaluate the presence of specific risk factors associated with the development of a swab-related infection.

Methods

All adults admitted to the Diagnostic and Therapeutic Medicine Department of the University Hospital Campus Bio-Medico of Rome with a diagnosis of infection or any other medical reason with admission surveillance swabs (rectal or nasal) between January 2018 and February 2021 were included in the study. A retrospective chart review was conducted to identify patients that developed infections with concordant MDROs identified on ASC, and the risk factors for swab-related infection. Secondary outcomes were need of intensive care unit transfer, length of stay, sepsis or septic shock development, and all-cause mortality.

Results

A total of 528 patients were included in the study, of which 97 (18.3%) had a positive surveillance swab. Among patients with positive surveillance swabs, 18 (18.5%) developed an infection with the same microorganism recovered from the swab, 57 (58.8%) developed an infection with a different microorganism than that recovered from the surveillance swab, and 22 (22.7%) did not develop an infection during hospitalization. The number of colonized sites, an interventional procedure within the previous 3 months, a Systemic Inflammatory Response Syndrome (SIRS) score ≥ 2, and a quick Sequential Organ Failure Assessment (q-SOFA) score ≥ 2 were associated with a significantly higher risk of developing a swab-related infection. SIRS and q-SOFA scores ≥ 2 and procalcitonin ≥ 0.43 ng/ml help for identifying patients with a swab-related infection.

Conclusion

Patients with positive surveillance swabs were at increased risk for development of infections by the same MDRO identified in surveillance swabs (swab-related infection). This study is the first to show that the positivity of surveillance swabs, in combination with anamnestic data, PCT values, and SIRS or q-SOFA scores, serves as a valuable tool to help clinicians predict patients at higher risk for swab-related infection development and guide the administration of appropriate empiric antimicrobial therapy in septic patients.

Hematological Ratios Are Associated with Acute Kidney Injury and Mortality in Patients That Present with Suspected Infection at the Emergency Department

The early recognition of acute kidney injury (AKI) is essential to improve outcomes and prevent complications such as chronic kidney disease, the need for renal-replacement therapy, and an increased length of hospital stay. Increasing evidence shows that inflammation plays an important role in the pathophysiology of AKI and mortality. Several inflammatory hematological ratios can be used to measure systemic inflammation. Therefore, the association between these ratios and outcomes (AKI and mortality) in patients suspected of having an infection at the emergency department was investigated. Data from the SPACE cohort were used. Cox regression was performed to investigate the association between seven hematological ratios and outcomes. A total of 1889 patients were included, of which 160 (8.5%) patients developed AKI and 102 (5.4%) died in <30 days. The Cox proportional-hazards model revealed that the neutrophil-to-lymphocyte ratio (NLR), segmented-neutrophil-to-monocyte ratio (SMR), and neutrophil-lymphocyte-platelet ratio (NLPR) are independently associated with AKI <30 days after emergency-department presentation. Additionally, the NLR, SMR and NLPR were associated with 30-day all-cause mortality. These findings are an important step forward for the early recognition of AKI. The use of these markers might enable emergency-department physicians to recognize and treat AKI in an early phase to potentially prevent complications.

Clinical Significance of the Neutrophil–Lymphocyte Ratio as an Early Predictive Marker for Adverse Outcomes in Patients with Acute Cholangitis

Background and objectives: Acute cholangitis can be life-threatening if not recognized early. We investigated the predictive value of the neutrophil–lymphocyte ratio (NLR) in acute cholangitis. Materials and Methods: We retrospectively evaluated 206 patients with acute cholangitis who underwent biliary drainage. The severity of acute cholangitis was graded according to the Tokyo 2018 guideline. Patients were dichotomized according to the acute cholangitis severity (mild/moderate vs. severe), the presence of shock requiring a vasopressor/inotrope, and blood culture positivity. The baseline NLR, white blood cell (WBC) count, and C-reactive protein (CRP) levels were compared between groups. Results: The severity of acute cholangitis was graded as mild, moderate, or severe in 71 (34.5%), 107 (51.9%), and 28 (13.6%) patients, respectively. Ten patients (4.8%) developed shock. Positive blood culture (n = 50) was observed more frequently in severe acute cholangitis (67.9% vs. 17.4%, p < 0.001). The NLR was significantly higher in patients with severe cholangitis, shock, and positive blood culture. The area under the curve (AUC) for the NLR, WBC, and CRP for severe acute cholangitis was 0.87, 0.73, and 0.74, respectively. The AUC for the NLR, WBC, and CRP for shock was 0.81, 0.64, and 0.67, respectively. The AUC for the NLR, WBC, and CRP for positive blood culture was 0.76, 0.64, and 0.61, respectively; the NLR had greater power to predict disease severity, shock, and positive blood culture. The optimal cut-off value of the baseline NLR for the prediction of severe acute cholangitis, shock, and positive blood culture was 15.24 (sensitivity, 85%; specificity, 79%), 15.54 (sensitivity, 80%; specificity, 73%), and 12.35 (sensitivity, 72%; specificity, 70%), respectively. The sequential NLR values from admission to 2 days after admission were significantly higher in patients with severe cholangitis and shock. Conclusions: An elevated NLR correlates with severe acute cholangitis, shock, and positive blood culture. Serial NLR can track the clinical course of acute cholangitis.

The Utility of Peripheral Blood Leucocyte Ratios as Biomarkers in Neonatal Sepsis: A Systematic Review and Meta-Analysis

BACKGROUND

Early stage diagnosis of neonatal sepsis (NS) remains a major roadblock due to non-specific symptoms and the absence of precise laboratory index tests. The full blood count is a relatively cheap, universal, and rapid diagnostic test.

METHOD

This study assessed the diagnostic accuracies of immature-to-total neutrophil ratio (ITR), immature-to-mature neutrophil ratio (IMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) used in the diagnosis of NS. Included studies were retrieved by searching four major databases and relevant references, and reviewed based on the inclusion/exclusion criteria. Pooled sensitivities and specificities were calculated, I ² was utilized to test for heterogeneity, and the source was investigated via meta-regression analysis.

RESULTS

Finally, 38 studies passed the eligibility criteria. A total of thirty-one studies (6,221 neonates) included data on the ITR, eight studies (1,230 neonates) included data on the IMR, seven studies (751 neonates) included data on the NLR, and two studies (283 neonates) included data on the PLR. The summary sensitivity estimates with 95% confidence interval (CI) for the ITR, IMR, NLR, and PLR tests were, respectively, 0.74 (95% CI: 0.66-0.80), 0.74 (95% CI: 0.54-0.88), 0.73 (95% CI: 0.68-0.78), and 0.81 (95% CI: 0.55-1.00). The summary specificity values for the ITR, IMR, NLR, and PLR tests were 0.83 (95% CI: 0.77-0.87), 0.89 (95% CI: 0.80-0.94), 0.69 (95% CI: 0.57-0.79), and 0.93 (95% CI: 0.81-1.00), respectively. The area under the summary receiver operating characteristic curves for the ITR, IMR, and NLR tests were 0.85 (95% CI: 0.82-0.88), 0.91 (95% CI: 0.88-0.93), and 0.75 (95% CI: 0.71-0.79). The PLR could not be evaluated because only two studies included pertinent data.

CONCLUSION

The NLR test might not be sufficiently accurate in precisely diagnosing NS. The ITR and IMR tests alone can improve the accuracy of NS diagnosis, but the marked heterogeneity and the limited number of studies prevented us from reaching any definitive conclusions. Thus, further studies are warranted to validate these findings.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021247850].