Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit

IntroductionAbsolute lymphocytopenia has been reported as a predictor of bacteremia in medical emergencies. Likewise, the neutrophil-lymphocyte count ratio (NLCR) has been shown a simple promising method to evaluate systemic inflammation in critically ill patients.MethodsWe retrospectively evaluated the ability of conventional infection markers, lymphocyte count and NLCR to predict bacteremia in adult patients admitted to the Emergency Department with suspected community-acquired bacteremia. The C-reactive protein (CRP) level, white blood cell (WBC) count, neutrophil count, lymphocyte count and NLCR were compared between patients with positive blood cultures (n = 92) and age-matched and gender-matched patients with negative blood cultures (n = 92) obtained upon Emergency Department admission.ResultsSignificant differences between patients with positive and negative blood cultures were detected with respect to the CRP level (mean ± standard deviation 176 ± 138 mg/l vs. 116 ± 103 mg/l; P = 0.042), lymphocyte count (0.8 ± 0.5 × 109/l vs. 1.2 ± 0.7 × 109/l; P < 0.0001) and NLCR (20.9 ± 13.3 vs. 13.2 ± 14.1; P < 0.0001) but not regarding WBC count and neutrophil count. Sensitivity, specificity, positive and negative predictive values were highest for the NLCR (77.2%, 63.0%, 67.6% and 73.4%, respectively). The area under the receiver operating characteristic curve was highest for the lymphocyte count (0.73; confidence interval: 0.66 to 0.80) and the NLCR (0.73; 0.66 to 0.81).ConclusionsIn an emergency care setting, both lymphocytopenia and NLCR are better predictors of bacteremia than routine parameters like CRP level, WBC count and neutrophil count. Attention to these markers is easy to integrate in daily practice and without extra costs.

[1]  S. Korsmeyer,et al.  Prevention of lymphocyte cell death in sepsis improves survival in mice. , 1999, Proceedings of the National Academy of Sciences of the United States of America.

[2]  J. Fehr,et al.  The diagnostic value of the neutrophil left shift in predicting inflammatory and infectious disease. , 1997, American journal of clinical pathology.

[3]  M. ChB.,et al.  Neutrophil‐lymphocyte ratio as a prognostic factor in colorectal cancer , 2005, Journal of surgical oncology.

[4]  W. Knaus,et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. 1992. , 2009, Chest.

[5]  J. Stern,et al.  Extreme lymphocytopenia associated with toxic shock syndrome , 1998, Journal of internal medicine.

[6]  R. Hotchkiss,et al.  Apoptotic cell death in patients with sepsis, shock, and multiple organ dysfunction. , 1999, Critical care medicine.

[7]  W. Knaus,et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. , 1992, Chest.

[8]  Piotr Witkowski,et al.  Negative Impact of Neutrophil-Lymphocyte Ratio on Outcome After Liver Transplantation for Hepatocellular Carcinoma , 2009, Annals of surgery.

[9]  Paul N Valenstein,et al.  Trends in blood culture contamination: a College of American Pathologists Q-Tracks study of 356 institutions. , 2005, Archives of pathology & laboratory medicine.

[10]  G. Hillis,et al.  Preoperative neutrophil-lymphocyte ratio and outcome from coronary artery bypass grafting. , 2007, American heart journal.

[11]  M. Tsujita,et al.  Study of lymphocyte subpopulations in bone marrow in a model of protein-energy malnutrition. , 2010, Nutrition.

[12]  R. Gibbons,et al.  Predictive power of the relative lymphocyte concentration in patients with advanced heart failure. , 1998, Circulation.

[13]  J. Hanley,et al.  A method of comparing the areas under receiver operating characteristic curves derived from the same cases. , 1983, Radiology.

[14]  J. Vincent,et al.  The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure , 1996, Intensive Care Medicine.

[15]  H. Eichler,et al.  Regulation of adhesion molecules during human endotoxemia. No acute effects of aspirin. , 1999, American journal of respiratory and critical care medicine.

[16]  I. Chaudry,et al.  THE INDUCTION OF ACCELERATED THYMIC PROGRAMMED CELL DEATH DURING POLYMICROBIAL SEPSIS: CONTROL BY CORTICOSTEROIDS BUT NOT TUMOR NECROSIS FACTOR , 1995, Shock.

[17]  S. Mcnerlan,et al.  Age-related reference intervals for lymphocyte subsets in whole blood of healthy individuals. , 1999, Scandinavian journal of clinical and laboratory investigation.

[18]  R. Bonow,et al.  Relative lymphocyte count: a prognostic indicator of mortality in elderly patients with congestive heart failure. , 2001, American heart journal.

[19]  Saxon Ridley.  Critical care. , 2003, Anaesthesia.

[20]  P. Collignon,et al.  Profound lymphopenia and bacteraemia , 2006, Internal medicine journal.

[21]  A. Cross,et al.  Simultaneous activation of apoptosis and inflammation in pathogenesis of septic shock: a hypothesis 1 , 2003, FEBS letters.

[22]  T. Peto,et al.  Relation between lymphopenia and bacteraemia in UK adults with medical emergencies , 2004, Journal of Clinical Pathology.

[23]  E. Draper,et al.  APACHE II: A severity of disease classification system , 1985, Critical care medicine.

[24]  M. N. Lutfiyya,et al.  Diagnosis and treatment of community-acquired pneumonia. , 2006, American family physician.

[25]  P. Póvoa,et al.  C-reactive protein as an indicator of sepsis , 1998, Intensive Care Medicine.

[26]  B. Drénou,et al.  Early Circulating Lymphocyte Apoptosis in Human Septic Shock Is Associated with Poor Outcome , 2002, Shock.

[27]  R. Záhorec.  Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill. , 2001, Bratislavske lekarske listy.

[28]  M. Weinstein.  Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. , 1996, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[29]  R. Hotchkiss,et al.  Apoptosis in lymphoid and parenchymal cells during sepsis: findings in normal and T- and B-cell-deficient mice. , 1997, Critical care medicine.

[30]  T. Peto,et al.  Bacteraemia prediction in emergency medical admissions: role of C reactive protein , 2005, Journal of Clinical Pathology.

[31]  P. Fraker,et al.  The many roles of apoptosis in immunity as modified by aging and nutritional status. , 2004, The journal of nutrition, health & aging.

[32]  A. Nicholson,et al.  Neutrophil/lymphocyte ratio and its association with survival after complete resection in non-small cell lung cancer. , 2009, The Journal of thoracic and cardiovascular surgery.

[33]  L. Leibovici,et al.  Bacteremia in febrile patients. A clinical model for diagnosis. , 1991, Archives of internal medicine.

[34]  K. Wood,et al.  Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock* , 2006, Critical care medicine.

[35]  I. Chaudry,et al.  Differential induction of apoptosis in lymphoid tissues during sepsis: variation in onset, frequency, and the nature of the mediators. , 1996, Blood.

[36]  S. Greenfield,et al.  The complete blood count and leukocyte differential count. An approach to their rational application. , 1987, Annals of internal medicine.

[37]  D. Goodman,et al.  Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis. , 1995, The American surgeon.

[38]  K. Eagle,et al.  Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. , 2008, The American journal of cardiology.

[39]  M. Safar,et al.  Diagnosis and follow-up of infections in intensive care patients: value of C-reactive protein compared with other clinical and biological variables. , 2002, Critical care medicine.

[40]  D. Mozaffarian,et al.  Usefulness of relative lymphocyte count as an independent predictor of death/urgent transplant in heart failure. , 2005, The American journal of cardiology.

[41]  H. Malik,et al.  Elevated preoperative neutrophil to lymphocyte ratio predicts survival following hepatic resection for colorectal liver metastases. , 2008, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[42]  D. Bates,et al.  How bad are bacteremia and sepsis? Outcomes in a cohort with suspected bacteremia. , 1995, Archives of internal medicine.

[43]  J. Nuutila,et al.  Distinction between bacterial and viral infections , 2007, Current opinion in infectious diseases.