Diagnostic values of red cell distribution width, platelet distribution width and neutrophil-lymphocyte count ratio for sepsis

The causal relationship between blood cell indices and 28-day mortality in sepsis: a retrospective study and bidirectional Mendelian randomization analysis

BACKGROUND

Despite emerging evidence linking blood cell indices (BCIs) to sepsis mortality, the inconsistency of observational studies obscures the clarity of these associations. This study aims to clarify the causal influence of BCIs on 28-day mortality rates in sepsis patients.

METHODS

Utilizing univariable and multivariable Mendelian randomization (MR) analyses, we examined the impact of BCIs on sepsis mortality by analyzing data from extensive genome-wide association studies. The inverse-variance weighted (IVW) method was our primary analytic tool, complemented by several robustness checks to mitigate pleiotropy, including weighted median, mode-based estimates, MR-Egger regression, and MR-PRESSO. Subsequently, we conducted a retrospective study to further explore the correlation between platelet indices and 28-day mortality of sepsis using real-world data.

RESULTS

Our findings highlight a significant causal relationship between platelet distribution width (PDW) and 28-day mortality in sepsis, with the univariable Mendelian randomization approach yielding an odds ratio of 1.12 (95% CI, 1.06-1.26; P < 0.05). Multivariable analysis further substantiated PDW's robust association with mortality risk (OR 1.23; 95% CI, 1.03-1.48; P < 0.05). Conversely, our analysis did not uncover significant correlations between the genetic predispositions to other BCIs-including red blood cell count, erythrocyte distribution width, platelet count, mean platelet volume, white blood cell count, neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage-and 28-day mortality in sepsis. Additionally, an inverse MR analysis did not establish a causal impact of 28-day mortality in sepsis on PDW (OR 1.00; 95% CI, 1.00-1.07; P = 0.29). Moreover, a similar result was observed in the retrospective study.

CONCLUSIONS

The study underscores the independent causal role of PDW in predicting 28-day mortality in sepsis, suggesting its potential utility in early patient assessment, risk stratification, and tailoring of therapeutic interventions.

Establishment of a mortality risk nomogram for predicting in-hospital mortality of sepsis: cohort study from a Chinese single center

Objective

To establish a mortality risk nomogram for predicting in-hospital mortality of sepsis patients in the Chinese population.

Methods

Data were obtained from the medical records of sepsis patients enrolled at the Affiliated Huadu Hospital, Southern Medical University, between 2019 and 2021. A total of 696 sepsis patients were initially included in our research, and 582 cases were finally enrolled after screening and divided into the survival group (n = 400) and the non-survival group (n = 182) according to the incidence of mortality during hospitalization. Twenty-eight potential sepsis-related risk factors for mortality were identified. Least absolute shrinkage and selection operator (LASSO) regression was used to optimize variable selection by running cyclic coordinate descent with k-fold (tenfold in this case) cross-validation. We used binary logistic regression to build a model for predicting mortality from the variables based on LASSO regression selection. Binary logistic regression was used to establish a nomogram based on independent mortality risk factors. To validate the prediction accuracy of the nomogram, receiver operating characteristic curve (ROC) analysis, decision curve analysis (DCA) and restricted cubic spline (RCS) analysis were employed. Eventually, the Hosmer-Lemeshow test and calibration curve were used for nomogram calibration.

Results

LASSO regression identified a total of ten factors, namely, chronic heart disease (CHD), lymphocyte count (LYMP), neutrophil-lymphocyte ratio (NLR), red blood cell distribution width (RDW), C reactive protein (CRP), Procalcitonin (PCT), lactic acid, prothrombin time (PT), alanine aminotransferase (ALT), total bilirubin (Tbil), interleukin-6 (IL6), that were incorporated into the multivariable analysis. Finally, a nomogram including CHD, LYMP, NLR, RDW, lactic acid, PT, CRP, PCT, Tbil, ALT, and IL6 was established by multivariable logistic regression. The ROC curves of the nomogram in the training and validation sets were 0.9836 and 0.9502, respectively. DCA showed that the nomogram could be applied clinically if the risk threshold was between 29.52 and 99.61% in the training set and between 31.32 and 98.49% in the testing set. RCS showed that when the value of independent risk factors from the predicted model exceeded the median, the mortality hazard ratio increased sharply. The results of the Hosmer-Lemeshow test (χ2 = 0.1901, df = 2, p = 0.9091) and the calibration curves of the training and validation sets showed good agreement with the actual results, which indicated good stability of the model.

Conclusion

Our nomogram, including CHD, LYMP, NLR, RDW, lactic acid, PT, CRP, PCT, Tbil, ALT, and IL6, exhibits good performance for predicting mortality risk in adult sepsis patients.

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.

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].

Umbilical cord blood hematological parameters in predicting early onset neonatal sepsis (EOS) - a prospective cohort study

OBJECTIVES

In low and middle income countries, there is a need for affordable and accurate biomarkers to identify neonates at risk of early onset neonatal sepsis (EOS). Cord blood hematological parameters if reliable and accurate for the detection of EOS are cost effective and can reduce the need for repeated venipuncture in the neonate.

METHODS

In this prospective cohort study, the umbilical cord parameters of newborns with gestational age >34 weeks were collected. These neonates were followed up for 72 h and septic screen was employed in those babies who had risk factors or developed clinical features of sepsis. The cord blood parameters of the normal newborn and those who had sepsis were analyzed.

RESULTS

A total of 513 neonates were enrolled for the study, 32 required septic screening of whom 13 neonates were found to meet the criteria for sepsis: either blood culture positive or sepsis screen positive with clinical features. Cord blood parameters were analyzed using independent t test. Red cell distribution width (RDW) and band cells were statistically significant (p 0.007 and 0.009 respectively) between the septic and normal neonates. Increased RDW had a sensitivity of 61.54 %, specificity of 54.60 %. Increased band cells with a cut off of >15 cells had a sensitivity of 7.7 % with specificity of 100 % with higher numbers in septic neonates. Increased RDW and band cells in combination had sensitivity of 61.54 % and specificity of 54.6 %.

CONCLUSIONS

RDW and band cell can be potential markers of EOS in cord blood but require further study in a larger population.

C-Reactive Protein-to-Albumin Ratio (CAR) and C-Reactive Protein-to-Lymphocyte Ratio (CLR) are Valuable Inflammatory Biomarker Combination for the Accurate Prediction of Periprosthetic Joint Infection

Background

Periprosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty (TJA). Timely and accurate diagnosis is important for the management of PJI. Currently, many biomarkers are available for the diagnosis of PJI, but which inflammatory biomarker combination has the best diagnostic value has not been reported.

Materials and Methods

We retrospectively analyzed 244 patients who underwent revision knee or hip arthroplasty in our institution. They were divided into two groups: 87 in the PJI group and 157 in the aseptic failure (AF) group. The preoperative C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), CRP-to-albumin ratio (CAR), CRP-to-lymphocyte ratio (CLR), neutrophil-to-albumin ratio (NAR) and platelet-to-albumin ratio (PAR) were determined and compared between the two groups. Receiver operating characteristic curve (ROC) and area under the curve (AUC) were used to assess the diagnostic value of all biomarkers, and the optimal cut-off value, positive predictive value (PPV) and negative predictive value (NPV) were further calculated by the Youden index.

Results

The NLR, PLR, CAR, CLR, NAR and PAR of the PJI group were significantly higher than those of the AF group (P<0.001). According to the ROC and AUC results, the diagnostic value of CAR and CLR was considered excellent with AUCs of 0.931 and 0.935, respectively. The diagnostic value of NAR (0.739) and PAR (0.785) were fair, the diagnostic value of NLR (0.694) was poor, and PLR (0.535) had no diagnostic ability. Subgroup analysis showed no significant differences in combined inflammatory biomarkers between the two groups.

Conclusion

CAR and CLR are valuable combined inflammatory biomarkers for diagnosing PJI, while other markers were of limited value for the diagnosis of PJI.

Evaluation of the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in critically ill dogs

OBJECTIVE

To evaluate whether the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are accurate prognostic indicators and correlate with illness severity scores in critically ill dogs.

DESIGN

Prospective observational study from December 2016 to May 2017.

SETTING

ICU at a veterinary teaching hospital.

ANIMALS

Seventy-two client-owned dogs admitted to the ICU with CBCs and abbreviated and complete acute patient physiologic and laboratory evaluation (APPLE_fast and APPLE_full ) scores were enrolled.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The NLR, PLR, APPLE_fast , and APPLE_full scores were calculated for each patient on the day of admission. Patients were followed from admission to discharge, and diagnosis, survival, and length of hospitalization were recorded. The patient population was assessed as a whole and as subcategories of patients with neoplastic disease, infectious disease, sepsis, and severe hemorrhage. Dogs with nonseptic disease processes (n = 52) that died had a significantly higher median PLR (P = 0.04) of 441 (range: 106-986) compared to those that survived with a median PLR of 217 (range: 28.4-3225). The PLR was strongly predictive of ICU length of stay in dogs with severe hemorrhage (P = 0.03, Spearman's rho = 0.84). The NLR had a poor positive correlation with APPLE_full score (P = 0.04, Spearman's rho = 0.24), and PLR had a poor negative correlation with APPLE_fast score (P = 0.02, Spearman's rho = -0.27).

CONCLUSIONS

The PLR correlated with ICU length of stay for patients with severe hemorrhage and with survival for patients with nonseptic disease processes. The PLR and NLR correlated with illness severity as measured by APPLE scores. Future studies with larger sample sizes are warranted to further determine the merit of NLR and PLR as indicators of morbidity, mortality, and illness severity.

Diagnostic value of RDW for the prediction of mortality in adult sepsis patients: A systematic review and meta-analysis

Background

Red blood cell distribution width (RDW) is a common biomarker of bacterial infections, and it can be easily obtained from a routine blood test. We investigate the diagnostic value of RDW for the prediction of mortality in adult sepsis patients through a review and meta-analysis. We registered this review in PROSPERO (Registration Number: CRD42022357712), and the details of the registration are included in Appendix 1.

Methods

We searched PubMed, Cochrane Library, Springer, and Embase between Jan. 1, 2000, and May 30, 2022, for primary studies about this research. We collected articles that investigated RDW for varying degrees of sepsis patients—those who suffered from sepsis, severe sepsis, or sepsis shock. Studies of healthy people and sepsis of children and neonates were excluded from our research. The definition of study characteristics and data extraction were finished by two independent researchers and discrepancies resolved by consensus. The combined sensitivities and specificities were calculated by meta-analysis using STATA14.0. The sensitivity of the included studies was analyzed by excluding studies that had potential heterogeneity. A summary operating characteristic curve was made to evaluate the diagnostic value for the prediction of mortality in adult sepsis patients. The Fagan test was used to explore likelihood ratios and posttest probabilities. Finally, we investigated the source of heterogeneity using meta-regression.

Results

Twenty-four studies, including 40,763 cases altogether, were included in this analysis. Bivariate analysis indicated a combined sensitivity of 0.81 (95% CI 0.73–0.86) and specificity of 0.65 (95% CI 0.54–0.75). The area under the summary receiver operating characteristic curve was 0.81 (95% CI 0.77–0.84). Substantial heterogeneity resided in the studies (I^{2 =}96.68, 95% CI 95.95–97.4). Meta-regression showed that the reference description, prospective design, and blinded interpretation of the included studies could be responsible for the heterogeneity.

Conclusions

RWD is an available and valuable biomarker for prediction of mortality in adult sepsis patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022357712.

The association of vitamin D deficiency with hemogram-derived inflammatory biomarkers in children

BACKGROUND AND AIMS

One of the extraosseous effects of vitamin D is that it is a potent modulator of inflammatory processes. Many studies have demonstrated the inverse association between vitamin D and inflammation. Therefore, we hypothesize that vitamin D deficiency may affect the inflammatory markers derived from hemogram parameters [neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), platelet distribution width (PDW), red blood cell distribution width (RDW)] in healthy children.

METHODS AND RESULTS

We conducted a retrospective study on healthy children. From 2015 to 2020, 16,321 children with simultaneous vitamin D and hemogram measurements were identified from electronic records. Participants were divided into 2 groups according to whether they had vitamin D deficiency or not. The relationship between vitamin D status and the levels of inflammatory markers was analyzed. All inflammatory markers showed statistically significant differences between vitamin D status (p < 0.001 for all). Vitamin D levels were significantly negatively correlated with NLR (r = -0.285), PLR (r = -0.257), PDW (r = -0.181), and positively correlated with LMR (r = 0.218), and RDW (r = 0.057). In logistic regression analysis, age (OR = 1.15, 95% CI: 1.14-1.16), gender (OR = 1.66, 95% CI: 1.54-1.78), LMR (OR = 0.96, 95% CI: 0.95-0.98), PLR (OR = 1.003, 95% CI: 1.001-1.004), and RDW (OR = 1.10, 95%CI: 1.07-1.13) were found to be independent predictors for vitamin D deficiency.

CONCLUSIONS

Statistically significant differences were detected between vitamin D status and inflammatory parameters. However, the difference between the median values of vitamin D groups was very small and the degree of correlation was very weak. Therefore, the clinical significance of the difference should be questioned.

Factors associated with in-hospital mortality in adult sepsis with Escherichia coli infection

Background

Escherichia coli (E. coli) is an important pathogen in sepsis. This study aimed to explore the factors which were associated with in-hospital mortality in adult sepsis with E. coli infection based on a public database.

Methods

All sepsis patients with E. coli infection in MIMIC-III were included in this study. Clinical characteristics between the survivor and non-survivor groups were analyzed. Factors associated with in-hospital mortality were identified by multivariate logistic regression.

Results

A total of 199 patients were eventually included and divided into two groups: a survivor group (n = 167) and a non-survivor group (n = 32). RDW and HCT were identified as the factors with clinical outcomes. The area under the ROC curve (AUC) were 0.633 and 0.579, respectively. When combined RDW and HCT for predicting in-hospital mortality, the AUC was 0.772, which was significantly superior to SOFA and APACHEII scores.

Conclusion

RDW and HCT were identified as factors associated with in-hospital mortality in adult sepsis patients with E. coli infection. Our findings will be of help in early and effective evaluation of clinical outcomes in those patients.

Neutrophil to Lymphocyte Ratio (NLR)—A Useful Tool for the Prognosis of Sepsis in the ICU

Sepsis is a life-threatening medical emergency induced by the body′s extreme response to an infection. Despite well-defined and constantly updated criteria for diagnosing sepsis, it is still underdiagnosed worldwide. Among various markers studied over time, the neutrophil to lymphocyte ratio (NLR) recently emerged as a good marker to predict sepsis severity. Our study was a single-center prospective observational study performed in our ICU and included 114 patients admitted for sepsis or septic shock. Neutrophil to lymphocyte ratio (NLR) is easy to perform, CBC being one of the standard blood tests routinely performed upon admission for all ICU patients. We found that NLR was increased in all patients with sepsis and significantly raised in those with septic shock. NLR correlates significantly with sepsis severity evaluated by the SOFA score (R = 0.65) and also with extensively studied sepsis prognosis marker presepsin (R = 0.56). Additionally, NLR showed good sensitivity (47%) and specificity (78%) with AUC = 0.631 (p < 0.05). NLR is less expensive and easier to perform compared with other specific markers and may potentially become a good alternate option for evaluation of sepsis severity. Larger studies are needed in the future to demonstrate the prognosis value of NLR.

The Value of a Complete Blood Count (CBC) for Sepsis Diagnosis and Prognosis

Sepsis represents an important global health burden due to its high mortality and morbidity. The rapid detection of sepsis is crucial in order to prevent adverse outcomes and reduce mortality. However, the diagnosis of sepsis is still challenging and many efforts have been made to identify reliable biomarkers. Unfortunately, many investigated biomarkers have several limitations that do not support their introduction in clinical practice, such as moderate diagnostic and prognostic accuracy, long turn-around time, and high-costs. Complete blood count represents instead a precious test that provides a wealth of information on individual health status. It can guide clinicians to early-identify patients at high risk of developing sepsis and to predict adverse outcomes. It has several advantages, being cheap, easy-to-perform, and available in all wards, from the emergency department to the intensive care unit. Noteworthy, it represents a first-level test and an alteration of its parameters must always be considered within the clinical context, and the eventual suspect of sepsis must be confirmed by more specific investigations. In this review, we describe the usefulness of basic and new complete blood count parameters as diagnostic and prognostic biomarkers of sepsis.

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

Background and Objectives: The aim of this study was to evaluate the diagnostic accuracy and prognostic value of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios and to compare them with other biomarkers and clinical scores of sepsis outside the intensive care unit. Materials and methods: In this retrospective study, 251 patients with sepsis and 126 patients with infection other than sepsis were enrolled. NLR and PLR were calculated as the ratio between absolute values of neutrophils, lymphocytes, and platelets by complete blood counts performed on whole blood by Sysmex XE-9000 (Dasit, Italy) following the manufacturer’s instruction. Results: The best NLR value in diagnosis of sepsis was 7.97 with sensibility, specificity, AUC, PPV, and NPV of 64.26%, 80.16%, 0.74 (p < 0.001), 86.49%, and 53.18%, respectively. The diagnostic role of NLR significantly increases when PLR, C-reactive protein (PCR), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) values, as well as systemic inflammatory re-sponse syndrome (SIRS), sequential organ failure assessment (SOFA), and quick-sequential organ failure assessment (qSOFA) scores, were added to the model. The best value of NLR in predicting 90-day mortality was 9.05 with sensibility, specificity, AUC, PPV, and NPV of 69.57%, 61.44%, 0.66 (p < 0.0001), 28.9%, and 89.9%, respectively. Sensibility, specificity, AUC, PPV, and NPV of NLR increase if PLR, PCR, PCT, MR-proADM, SIRS, qSOFA, and SOFA scores are added to NLR. Conclusions: NLR and PLR represent a widely useful and cheap tool in diagnosis and in predict-ing 90-day mortality in patients with sepsis.

Elevated Red Cell Distribution Width as a Useful Marker in Neonatal Sepsis

Neonatal sepsis is an important cause of neonatal morbidity and mortality in the neonatal intensive care unit. Red blood cell distribution width (RDW) is an important and independent prognostic factor in several diseases. The objective of this study was to evaluate the diagnostic value of RDW in neonatal sepsis. An observational, retrospective cohort study was conducted on newborns admitted to the neonatal intensive care unit in a Tertiary Care University Hospital between 2016 and 2019. Patients were classified into sepsis and control groups. Demographic characteristics and laboratory findings including RDW were analyzed. RDW was significantly higher in the sepsis group than in the control group (P=0.001). RDW had an area under the receiver operating characteristic curve of 0.799 for the diagnosis of sepsis. The sensitivity and specificity of an RDW value of 17.4% were found to be 60% and 88.3%, respectively (P=0.001). Multivariable logistic regression analysis showed a positive association of RDW with sepsis (odds ratio: 2.71; 95% confidence interval: 2.19-3.36; P=0.001). RDW value was significantly higher in neonatal sepsis and could be used as a useful alternative to other assessment tools as a readily available biomarker.

Evaluation of prognostic significance of hematological profiles after the intensive phase treatment in pulmonary tuberculosis patients from Romania

We evaluated in this cohort study the predictive ability of 23 peripheral blood parameters and ratios for treatment outcomes after the 2-month intensive phase in patients with PTB. In 63 patients out of 90 that turned culture negative, a significant decrease in white blood cell count, neutrophils, monocyte, hemoglobin, platelet, plateletcrit, erythrocyte sedimentation rate, MLR, NLR, PLR and SII values after anti-TB therapy compared to pretreatment was observed (p <0.001). Logistic regression analysis generated a model of predictors consisting of nine covariates. Spearman’s correlation analysis revealed significant positive correlations between NLR with NEU (r = 0.79, p<0.01), SII with NEU (r = 0.846, p<0.01), PLT with SII (r = 0.831, p<0.01), PLT with PCT (r = 0.71, p<0.01) and MPV with P-LCR (r = 0,897, p<0.01) in 63 patients out of 90 that turned culture negative after 2 months of treatment. ROC curve analysis indicated that all areas under the curve (AUC) revealed no statistically significant results, except lymphocyte for culture conversion. In summary, here we observed a set of hematological parameters that declined significantly as the disease was treated in patients that turned culture negative. Despite some limitations, our findings are useful for further studies aiming to identify hematological profiles that could predict the treatment outcome.

Are Leukocyte and Platelet Abnormalities and Complete Blood Count Ratios Potential Prognostic Markers in Canine Sepsis?

Background: Sepsis is a common disease in which early diagnosis and prognosis assessment are the main aims in order to arrange a prompt and effective treatment. Objectives: (1) To compare leukogram parameters (WBC, segmented and band neutrophils, lymphocytes, monocytes), platelet count (PLT), mean platelet volume (MPV), and some leukocyte/platelet ratio such as NLR, NBNLR, PLR, and MLR between dogs with systemic inflammatory response syndrome (SIRS) and sepsis. (2) To investigate any difference in the trend of these latter parameters between survivors and non-survivors septic dogs. Animals: 57 dogs with confirmed sepsis and 57 dogs with non-septic SIRS. Methods: A review of the medical records was conducted in order to find dogs with sepsis. Sepsis was defined as the presence of an infectious focus with fulfillment of systemic inflammatory response syndrome criteria (SIRS). Septic dogs had to have a CBC at admission and another CBC within 48 h from the previous timepoint. Purebreds with CBC breed-related abnormalities were excluded, together with dogs without confirmed sepsis and dogs with only a single CBC. NLR, NBNLR, PLR, and MLR were calculated. Univariate analysis of all blood parameters studied was assessed between SIRS and septic dogs. Generalized Estimating Equations models for repeated measures were used to test if the blood parameters studied were modified between survivors and non-survivors in the septic group. Results: Septic dogs had lower median segmented neutrophils count and NLR compared to SIRS dogs (p = 0.02 and p = 0.04, respectively). Lastly, septic dogs had a higher prevalence of toxic neutrophil than SIRS dogs (p = 0.01). We found that for a 1-unit increase of PLR and MLR, the risk of death increased by 50.5 and 60%, respectively. Conclusion and Clinical Importance: Evaluation of NLR at hospital admission may be a useful marker of inflammation, although it showed low sensitivity in differentiating SIRS and septic dogs. The monitoring of some CBC parameters, especially PLR and MLR may be useful in the establishment of prognosis in septic dogs.

Leucocyte ratios are biomarkers of mortality in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure

BACKGROUND

In patients with cirrhosis, progression to acute decompensation (AD) and acute-on-chronic liver failure (ACLF) has been associated with poor prognosis. Differential leucocyte ratios might predict mortality in systemic inflammatory conditions.

AIM

To evaluate differential leucocyte ratios as prognostic biomarkers in patients with cirrhosis.

METHODS

Patients with AD and ACLF were recruited from four centres in three countries. Peripheral blood differential leucocytes were measured (three centres using flow cytometry) on hospital admission and at 48 hours. Ratios were correlated to model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure (CLIF-SOFA), suspected/culture-positive bacterial infection and survival.

RESULTS

Nine hundred twenty-six patients (562 (61%) male, median age 55 (25-94) years) were studied. Overall, 350 (37%) did not survive to hospital discharge. Neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR) were elevated in patients with AD and ACLF who died during their hospital stay. On multivariate analysis NLR retained statistical significance independently of CLIF-SOFA or MELD. NLR >30 was associated with an 80% 90-day mortality in patients with ACLF but not AD. On sensitivity analysis for subgroups (alcohol-related liver disease and suspected sepsis), NLR and MLR retained statistically robust accuracy for the prediction of mortality. Significant predictive accuracy was only observed in centres using flow cytometry.

CONCLUSION

Leucocyte ratios are simple and robust biomarkers of outcome in ACLF, which are comparable to CLIF-SOFA score but dependent on leucocyte quantification method. NLR and MLR may be used as screening tools for mortality prediction in patients with acutely deteriorating cirrhosis.

New Diagnostic Possibilities for Early Onset Neonatal Sepsis: Red Cell Distribution Width to Platelet Ratio

Aims: Red cell distribution width to platelet ratio (RPR) has been reported as a useful inflammatory marker and prognostic indicator of adult inflammatory diseases. In the present study, red cell distribution width (RDW) and RPR parameters, which are parts of a complete blood count analysis, were compared to the traditional C reactive protein (CRP) and procalcitonin (PCT) parameters to investigate the potential to predict early onset sepsis (EOS) in neonates with or without positive blood cultures. Methods: An observational, retrospective cohort study was conducted to evaluate newborns born in our hospital. Results: RDW, RPR, CRP, PCT, Immature to total neutrophil ratio (I/T), and white blood cell (WBC) counts were higher in suspected and proven EOS compared to control group. Conclusion: We believe that RPR may be used in diagnosis of early onset neonatal sepsis and may be a good alternative to other tools as a readily available biomarker.

Slow-Release and Nontoxic Pickering Emulsion Platform for Antimicrobial Peptide

The resistance in microorganisms against many conventional antibiotics has become a serious global health problem. However, antibacterial drug delivery materials are still limited in toxicity, short efficacy and reducing inflammation. The novel and natural Pickering emulsions stabilized by antimicrobial peptide nanoparticles were tested as promising platforms to control bacterial resistance development. The parasin I interacted or conjugated with lecithin or chitosan and formed nanoparticles encapsulated by Pickering emulsion. The protonation and deprotonation of amino groups in chitosan and parasin I resulted in nanoparticles in different aggregate states and changed emulsion stability. Moreover, the Pickering emulsion could induce severe bacterial agglomeration on both Gram-positive and Gram-negative bacteria than parasin I through the membrane disintegration mechanism. Furthermore, the Pickering emulsion could alleviate the cytotoxicity of human liver cells and hemolytic activity in rat blood cells. In combination with the lack of acute cytotoxicity in Kunming mice and milder, more effective anti-inflammatory effect in peritonitis demonstrated for these Pickering emulsions, especially chitosan peptide-embedded nanoparticles Pickering emulsion, a potential role in combating multidrug resistant bacteria in biomedical applications.

Diagnostic values of neutrophil/lymphocyte ratio, platelet/lymphocyte ratio and procalcitonin in early diagnosis of bacteremia

Objective

The aim of this study is to investigate the diagnostic accuracy of complete blood count (CBC), C-reactive protein (CRP), and procalcitonin (PCT) levels, which can be used as a cultural alternative for the diagnosis of infection faster.

Methods

The patients were divided into two groups as bacteremia (n = 220) and nonbacteremia group (n = 812). The bacteremia group was divided into two subgroups as Gram-positive bacteria (n = 167) and Gram-negative bacteria (n = 53).

Results

PCT, CRP, red blood cell distribution width (RDW), platelet distribution width (PDW), neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR), and mean platelet volume (MPV) levels were significantly higher in patients with positive blood culture than non-patients. The serum PCT levels were 3.80 (0.83–37.68) and 0.43 (0.16–2.61) ng/mL, respectively (p < 0.001) in the patients with Gram-negative and Gram-positive bacterium. PCT at a cut-off value of 0.45 ng/mL for Gram-negative bacterium; sensitivity of 90% and specificity of 64%.

Conclusions

It is important that RDW, PDW, NLR, PLR, MPV values can be measured quickly, easily and cheaply by automatic hematological analysis. However, among the markers tested, PCT has the best diagnostic performance for Gram-negative bacteremia.

The usefulness of neutrophil/lymphocyte count ratio in the diagnosis and prognosis of bacterial sepsis – An old parameter with new implications

Aims: To analyze the diagnostic role of neutrophil/lymphocyte count ratio (NLCR) in sepsis and to evaluate its usefulness in appreciating the prognosis of septic patients.

Methods : A prospective analysis of patients diagnosed with sepsis between October 2015 and July 2017 was performed. A control group of patients with systemic inflammatory response syndrome (SIRS) with noninfectious causes was recruited. The sensitivity, specificity and AUC of NCLR for sepsis diagnosis were comparatively assessed with other biomarkers including fibrinogen (FIB), C-reactive protein (CRP) and procalcitonin (PCT). The baseline levels of NLCR were correlated with APACHE IV, APS and SOFA scores of severity.

Results : We enrolled 105 patients with sepsis and 37 patients with noninfectious SIRS. NLCR had significantly higher levels in the first group (p---lt---0.05). For an optimal cut-off value of 8.18, the sensitivity, specificity and AUC of NLCR for sepsis diagnosis were 70.5%, 72.2% and 0.766, respectively. A cut-off value of 12.0 led to moderate sensitivity (58.7%) and moderate-to-high specificity (89%). For patients with SOFA score over 2 points, the characteristics did not significantly improve. The correlations between baseline NCLR and the severity scores were not statistically significant.

Conclusion : NLCR levels were significantly higher in sepsis group compared to noninfectious SIRS group. NLCR had moderate sensitivity and specificity regarding sepsis diagnosis. Baseline levels of NLCR did not correlate with the severity scores, so its usefulness in sepsis prognosis was limited.

The complete blood count to diagnose septic shock

The complete blood count has a longstanding role in the diagnosis of septic shock. Despite its limitations, this is a pragmatic tool because patients will generally have a blood count measured upon presentation to the hospital. Therefore, it is sensible to extract as much information from these values as possible. Although the white blood cell count continues to attract the most attention, it is the least useful. Emerging evidence suggests that emphasis should be shifted to the neutrophil to lymphocyte ratio (NLR) and perhaps the fraction of immune granulocytes.

Quantification of Immune Dysregulation by Next-generation Polymerase Chain Reaction to Improve Sepsis Diagnosis in Surgical Patients

OBJECTIVES

To quantify immunological dysfunction in surgical patients with presence/absence of sepsis using a droplet digital polymerase chain reaction (ddPCR) transcriptomic analysis. The study also aims to evaluate this approach for improving identification of sepsis in these patients.

BACKGROUND

Immune dysregulation is a central event in sepsis. Quantification of the expression of immunological genes participating in the pathogenesis of sepsis could represent a new avenue to improve its diagnosis.

METHODS

Expression of 6 neutrophil protease genes (MMP8, OLFM4, LCN2/NGAL, LTF, PRTN3, MPO) and also of 5 genes involved in the immunological synapse (HLA-DRA, CD40LG, CD3E, CD28, ICOS) was quantified in blood from 101 surgical patients with sepsis, 53 uninfected surgical patients, and 16 blood donors by using ddPCR. Areas under receiver operating characteristic curves (AUROC) and multivariate regression analysis were employed to test individual genes and gene ratios to identify sepsis, in comparison with procalcitonin.

RESULTS

Sepsis-induced overexpression of neutrophil protease genes and depressed expression of immunological synapse genes. MMP8/HLA-DRA, LCN2/HLA-DRA outperformed procalcitonin in differentiating between patients with sepsis and surgical controls in the AUROC analysis: LCN2/HLA-DRA: 0.90 (0.85-0.96), MMP8/HLA-DRA: 0.89 (0.84-0.95), procalcitonin: 0.80 (0.73-0.88) (AUROC, confidence interval 95%), and also in the multivariate analysis: LCN2/HLA-DRA: 8.57 (2.25-32.62); MMP8/HLA-DRA: 8.03 (2.10-30.76), procalcitonin: 4.20 (1.15-15.43) [odds ratio (confidence interval 95%)]. Gene expression levels of HLA-DRA were an independent marker of hospital mortality.

CONCLUSIONS

Quantifying the transcriptomic ratios MMP8/HLA-DRA, LCN2/HLA-DRA by ddPCR is a promising approach to improve sepsis diagnosis in surgical patients.

Platelet to Lymphocyte Ratio in Neonates: A Predictor of Early onset Neonatal Sepsis

Background

Neonatal sepsis (NS) is a common systemic disease that causes morbidity and mortality in newborns. But there is no ideal biomarker that can be used in the early diagnosis of NS. In recent studies, platelet to lymphocyte ratio (PLR) has been reported to play a critical role in the inflammatory process. In this study, we aimed to contribute to the research about whether or not PLR can be used as an early predictor of the diagnosis of NS.

Methods

This retrospective cohort study was conducted among the newborns born in İzmir Buca Maternity and Pediatric Hospital between March 2015–February 2016. During these twelve months, 611 neonates with Early-Onset Sepsis (EOS) were admitted to our neonatal intensive care unit. One hundred and forty-nine neonates with suspected EOS, 67 neonates with proven EOS and 92 healthy neonates were enrolled in the study.

Results

Platelet to lymphocyte ratio (PLR) values of the three groups were calculated 56.5 ± 17.8 vs. 62.4± 14.9 vs. 15.3 ± 2.1, respectively. PLR values of suspected or proven EOS group were significantly higher than the control group. PLR has AUC 0.89 to 0.93, the cutoff value of 39.5 to 57.7, the sensitivity of 88.9% to 91.3% and specificity of 94.7% to 97.6%, the positive predictive value of 94.3% to 97.4%, and negative predictive value of 88.6% to 91.8% in suspected and proven sepsis diagnosis.

Conclusions

Our results suggest that PLR can be used as a parameter in the prediction of neonatal sepsis.

Nonviral infection-related lymphocytopenia for the prediction of adult sepsis and its persistence indicates a higher mortality

Sepsis is a life-threatening disease that affects 30 million people worldwide each year. Despite the rapid advances in medical technology and organ support systems, it is still difficult to reduce the mortality rate. Early and rapid diagnosis is crucial to improve the treatment outcome. The aim of this study was to investigate the prediction efficiency of lymphopenia and other clinical markers, such as white blood cell (WBC), neutrophil count (N#), procalcitonin (PCT), and arterial lactic acid (Lac) in the diagnosis and prognosis assessment for adult patients with nonviral infection-related sepsis.A total of 77 sepsis- and 23 non-sepsis adult patients were enrolled in this study from September 2016 to September 2018. Daily lymphocyte count (Lym) of the patients was calculated until discharge or death. The diagnostic performance of the Lym and other biomarkers were compared using the area under the receiver operating characteristic curve (ROC) value.The level of Lym was decreased significantly in the sepsis group. Lym had a high diagnostic performance for sepsis, with an area under the curve (AUC) value of 0.971 (95% CI = 0.916-0.994). The diagnostic efficacy of Lym was more significant than WBC, N#, and PCT (P < .001). The results showed that the 28-day mortality rate of patients with continuous Lym <0.76 × 10/L was 39.66%, which significantly higher than patients without persistent lymphocytopenia.Lym is a promising, low cost, fast, and easily available biomarker for the diagnosis of sepsis. When nonviral infection is suspected and lymphocytopenia level is lower than the optimal cut-off (0.76 × 10/L) value, high vigilance is required for sepsis. The persistence with the lymphocytopenia cut-off value (<0.76 × 10/L) >3 days indicates a higher 28-day mortality rate.

Neutrophil-lymphocyte ratio in the early diagnosis of sepsis in an intensive care unit: a case-control study

OBJECTIVE

To evaluate the neutrophil-lymphocyte ratio as a predictor of sepsis and mortality in patients admitted to an intensive care unit.

METHODS

Case-control study of adult patients admitted to an intensive care unit. Patients who had sepsis as the reason for admission and who had a previous complete blood count examination were included as case patients. The following statistical analyses were performed: ROC curves, binary logistic regression, and Mann-Whitney and Pearson's chi-square tests. p < 0.05 was considered significant.

RESULTS

The ROC curve values were 0.62 for neutrophil-lymphocyte ratio, 0.98 for band neutrophils and 0.51 for total leukocytes. The presence of a neutrophil-lymphocyte ratio greater than 5.0, leukocyte count above 12,000mm3/mL and band neutrophil percentage above 10% were risk factors for sepsis; however, only the SAPS 3 and SOFA score were related to patient mortality.

CONCLUSION

The neutrophil-lymphocyte ratio and band neutrophils in combination with other parameters may be markers for the early detection of sepsis in intensive care units.

The utility of peripheral blood leucocyte ratios as biomarkers in infectious diseases: A systematic review and meta-analysis

OBJECTIVES

To assess the utility of the neutrophil:lymphocyte (NLR), lymphocyte:monocyte (LMR) and platelet:lymphocyte ratios (PLR) as infection biomarkers.

METHODS

PubMed/MEDLINE, Embase and Cochrane databases were searched to identify eligible articles. Studies of diagnosis, severity or outcome were included. PROSPERO systematic review registration CRD42017075032.

RESULTS

Forty studies were included, reporting on bacterial and viral infections, malaria, and critical illness due to sepsis. Ten studies reported an association of higher NLR with bacteraemia, supported by meta-analysis of patient-level data (five studies, n = 3320; AUC 0.72, p<0.0001) identifying a cut-off of >12.65. Two studies reported an association with lower LMR and diagnosis of influenza virus infection in patients with respiratory tract infection. Meta-analysis of patient-level data (n = 85; AUC 0.66, p = 0.01) identified a cut-off of ≤2.06. The directionality of associations between NLR and outcomes in heterogeneous cohorts of critically ill adults with sepsis varied. Potential clinical utility was also demonstrated in pneumonia (NLR), pertussis (NLR), urinary tract infection (NLR), diabetic foot infections (NLR) and Crimean Congo Haemorrhagic Fever (PLR). Longitudinal measurement of LMR during respiratory virus infection reflected symptoms and NLR during sepsis and bacteraemia predicted mortality.

CONCLUSIONS

Peripheral blood leucocyte ratios are useful infection biomarkers, with the most evidence related to diagnosis of bacteraemia and influenza virus infection. In critical illness due to sepsis, a signal towards an association with NLR and outcomes exists, and NLR should be evaluated in future stratification models. Longitudinal measurement of ratios during infection could be informative. Overall, these biomarkers warrant further recognition and study in infectious diseases.

The neutrophil-lymphocyte count ratio as a diagnostic marker for bacteraemia: A systematic review and meta-analysis

BACKGROUND

Bacteraemia is a common cause of increased morbidity and mortality in critically ill patients, but its early diagnosis and identification are complicated. The neutrophil-lymphocyte count ratio (NLCR) has been suggested as a useful indicator for the diagnosis of bacteraemia. We performed this meta-analysis to investigate the diagnostic accuracy of the NLCR for bacteraemia.

METHODS

We searched the PubMed, Embase, Web of Science, and Cochrane Library databases for this meta-analysis. We calculated individual and pooled sensitivities and specificities. I² statistics and Cochran's Q test were used to evaluate heterogeneity, and the cause of heterogeneity was explored with sensitivity analyses.

RESULTS

In total, 8 of 1086 eligible articles were included in the present meta-analysis. The pooled analyses revealed that the diagnostic accuracy of the NLCR in terms of its bacteraemia sensitivity was 0.723 [95% CI: 0.660, 0.777], and its specificity was 0.596 [95% CI: 0.556, 0.634]. The area under the summary receiver operating characteristic curve was 0.69 [95% CI 0.65-0.73].

CONCLUSION

The NLCR is an easy-to-collect marker for bacteraemia. However, the NLCR is inadequate, and only a combination of multiple biomarkers will improve its diagnostic accuracy for bacteraemia.

Utility and Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Dogs with Septic Peritonitis

Systemic inflammation is known to cause WBC abnormalities, specifically neutrophilia and lymphopenia. The neutrophil-to-lymphocyte ratio (NLR) is a simple and affordable biomarker that has been used in human clinical settings of sepsis but has not been investigated in veterinary species. We evaluated NLR in dogs with septic and nonseptic systemic inflammatory diseases and compared with a healthy dog population. An NLR ≥6 had an 84.39% sensitivity and 86.95% specificity to identify dogs with systemic inflammatory states; however, no ratio distinguished septic and nonseptic causes. The NLR was not associated with length of hospitalization, morbidity based on the acute patient physiologic laboratory evaluation scoring system, or mortality. The disassociation may be due to the retrospective nature of the study, including a restricted population size and acquisition of only a one-time blood sample. NLR is currently of limited use for diagnosis and prognosis in systemic inflammatory states in dogs, and larger, prospective studies are necessary to further evaluate NLR.

Neutrophil-to-Lymphocyte Ratio, Monocyte-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Mean Platelet Volume-to-Platelet Count Ratio as Biomarkers in Critically Ill and Injured Patients: Which Ratio to Choose to Predict Outcome and Nature of Bacteremia?

Background

Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume-to-platelet count (MPV/PC) ratio are readily available parameters that might have discriminative power regarding outcome. The aim of our study was to assess prognostic value of these biomarkers regarding outcome in critically ill patients with secondary sepsis and/or trauma.

Methods

A total of 392 critically ill and injured patients, admitted to surgical ICU, were enrolled in a prospective observational study. Leukocyte and platelet counts were recorded upon fulfilling Sepsis-3 criteria and for traumatized Injury Severity Score > 25 points. Patients were divided into four subgroups: peritonitis, pancreatitis, trauma with sepsis, and trauma without sepsis.

Results

NLR and MPV/PC levels were significantly higher in nonsurvivors (AUC/ROC of 0.681 and 0.592, resp., in the peritonitis subgroup; 0.717 and 0.753, resp., in the pancreatitis subgroup); MLR and PLR did not differ significantly. There was no significant difference of investigated biomarkers between survivors and nonsurvivors in trauma patients with and without sepsis except for PLR in the trauma without sepsis subgroup (significantly higher in nonsurvivors, AUC/ROC of 0.719). Independent predictor of lethal outcome was NLR in the whole cohort and in the peritonitis subgroup as well as MPV in the pancreatitis subgroup. Also, there were statistically significant differences in MPV/PC, MLR, and PLR values regarding nature of bacteremia. In general, the lowest levels had been found in patients with Gram-positive blood cultures.

Conclusions

NLR and MPV were very good independent predictors of lethal outcome. For the first time, we demonstrate that nature of bacteremia influences MPV/PC, MLR, and PLR. In heterogeneous cohort subgroup, analysis is essential.

The Importance of Haemogram Parameters in the Diagnosis and Prognosis of Septic Patients

Sepsis represents a severe pathology that requires both rapid and precise positive and differential diagnosis to identify patients who need immediate antimicrobial therapy. Monitoring septic patients’ outcome leads to prolonged hospitalisation and antibacterial therapy, often accompanied by substantial side effects, complications and a high mortality risk.

Septic patients present with complex pathophysiological and immunological disorders and with a predominance of pro-inflammatory or anti-inflammatory mediators which are heterogeneous with respect to the infectious focus, the aetiology of sepsis or patients’ immune status or comorbidities. Previous studies performed have analysed inflammatory biomarkers, but a test or combinations of tests that can quickly and precisely establish a diagnosis or prognosis of septic patients has yet to be discovered. Recent research has focused on re-analysing older accessible parameters found in the complete blood count to determine the sensitivity, specificity, positive and negative predictive values for the diagnosis and prognosis of sepsis.

The neutrophil/lymphocyte count ratio (NLCR), mean platelet volume (MPV) and red blood cells distribution width (RDW) are haemogram indicators which have been evaluated and which are of proven use in septic patients’ management.