The Application Of Neutrophil-lymphocyte Count Ratio In Community Acquired Pneumonia

Objective:community-acquired pneumonia is a common acute respiratory infectious diseases, severity classification of the disease and clinical outcome assessment have always been research hotspot and difficulty of clinical practice. It was increasingly suggested that the combining of pneumonia prognostic scales and biomarkers could improve the capacity for predicting severity of illness and adverse clinical outcomes in patients with community-acquired pneumonia. The study aims at exploring the application of neutral lymphocyte count ratio in the diagnosis and treatment of community-acquired pneumonia.Method:Plasma samples and clinical data were prospectively collected from 608 patients admitted with CAP in the respiratory department,General Hospital of Tianjin Medical University during January 2011 and April 2014. CURB-65 score and Clinical characteristics were collected upon hospitalization, including gender, age, complications(hypertension, diabetes, COPD, cerebrovascular disease, coronary heart disease, hepatitis, pulmonary tuberculosis, malignancy, liver function dysfunction) and antibiotic treatment before hospitalization(β- lactam, fluoroquinolone, macrocyclic lactones, other). Blood routine were measured within 24 hours after admission, including white blood cell count, neutrophil count, lymphocyte count and then NLCR were calculated. The basic vital signs(temperature, pulse, breathing rate, blood pressure),time to reach clinically stability, time of antibiotic treatment, hospitalization expenses, the cost of antibiotics, clinical trend and prognosis( stability, ICU admission, death) and other data were recorded during hospital stay.Result :(1)608 patients with CAP were included in our study, consisting of 327 males and 281 females with an average age of 54.14 + /- 22.60 years. The minimum was 0 and maximum was 3 of CURB-65 scores in all studied patients, with an average of 0.60 + /- 0.65.The number of cases in each group respectively were 296 cases, 266 cases,41 cases, 5 cases. Recording the basic physical signs of all patients,the percent of them reaching clinical stability was 427 cases(70.2%). Eventually 582 cases of patients discharged smoothly, 16 cases of patients required ICU admission, 10 cases of patients died.(2) with the advance of the CURB-65 score, the possibility of deterioration and death increased. In patients with CURB-65 score of 3 the percentage of adverse clinical outcomes was up to 20%.But the percentage of patients deterioration and death with a CURB-65 score of 1(19/266,7.14%)was higher than that of patients with a CURB-65 score of 2(2/41,4.88%).The percentage of patients death with a CURB-65 score of 1(8/266,3.01%)was higher than that of patients with a CURB-65 score of(1/41,2.44%).(3) with the increase of the CURB-65 score, white blood cell count(F = 4.60, P = 4.60), neutrophil counts(F = 7.90, P = 0.00) and NLCR(F = 13.59, P = 0.00) showed a trend of rising, and lymphocyte count(F = 0.22, P = 0.89) showed a trend of decline.(4) NLCR average was 6.34 + /- 12.43 and the CURB-65 score of majority of the patients with a NLCR >10 and NLCR ≤10 ranged from 0 to 1. 11.69%(9) of patients with a CURB-65 score 65 of 2 in NLCR >10 group and were higher than that in NLCR ≤10 group(31, 6.11%). 2.6%(2) of patients with a CURB-65 score 65 of 3 in NLCR >10 group and were higher than that in NLCR ≤10 group( 3, 0.59%).Time to reach clinical stability of patients with NLCR > 10(3.09 + /- 2.49) were longer than that of patients with NLCR ≤10(2.99 + /-2.22) and the variance was statistically significant(t = 5.25, P = 0.02). A percentage of 73.18%(371/507) patients in NLCR ≤10 group reached clinical stability within 72 hours,which is higher than that in NLCR > 10 group(40/77,51.95%). The variance was statistically significant(χ2 =19.51,P=0.00).The probability of deterioration and death in patients with NLCR ≤10(8/77,10.39%) was higher than that of patients with NLCR > 10(12/507,3.55%). The variance of stability(t=13.43,P=0.00)and death(t=12.40,P=0.00) between two groups were statistically significance.(5) COPD(Exp(B)=1.19), and WBC(Exp(B)=62.98), NLCR(Exp(B)=1.02), cerebrovascular disease(Exp(B)=1.19), diabetes(Exp(B)=1.68)were factors influencing early treatment failure within 72 h after hospitalization and age(Exp(B)=1.000),CURB-65score(Exp(B)=0.98), onset duration(Exp(B)=0.99) may be factors in relation with early treatment failure. while WBC(B=-4.14,sig=0.00)was significant factors.(6) The area under the ROC curve for predicting early treatment failure of White blood cell count(0.53), neutrophil counts(0.56), neutral lymphocyte ratio(0.61) was greater than 0.5, which was higher than the area under ROC curve of lymphocyte count(0.41).(7) The neutrophil number of patients who death(12.51 + /- 8.39) and ICU admission(9.66 + /- 9.46) were higher than that of stable patients(7.35 + /- 4.69). And the difference was statistically significant(F = 6.87, P = 6.87). The lymphocyte count of patients ICU admission(1.41 + 1.09) was lower than stable patients(1.91 + /- 2.99) and higher than death patients(1.35 + 0.84), but the difference was not statistically significant(F = 0.42, P = 0.42). The level of NLCR(21.19 + /- 37.55) of death CAP patients was significantly higher than that of patients required ICU admission(7.54+ /- 6.29), that of patients required mechanical ventilation(7.49 + /-8.14), and higher than that of discharge patients(6.04 + /- 11.57).And eventually the variance was statistically significant(F = 7.53, P = 0.00).(8) Age(Exp(B)=1.01), CURB-65 score(Exp(B)=1.80), hypertension(Exp(B)=4.22),coronary heart disease(Exp(B)=1.31),clinical stability(Exp(B)=1.01),neutrophil count(Exp(B)=2.87),lymphocyte count(Exp(B)=1.08), antibiotic use(Exp(B)=1.01)were risk factors for deterioration and death,onset duration(Exp(B)=0.99),NLCR(Exp(B)=0.99) may be risk factors for deterioration and death. None of the factors were significant risk factors.(9) The area under the ROC curve for deterioration and death of NLCR(AUC = 0.70) was highest, followed by CURB- 65 score(AUC = 0.67), neutrophils(AUC = 0.62), white blood cell count(AUC = 0.59) and tome to reach clinical stability(AUC = 0.51). Combining CURB-65 score and NLCR for drawing the ROC curve for predicting deterioration and death, NLCR could improve the area under ROC curve of CURB- 65 score for deterioration and death in patients with community-acquired pneumonia to 0.73(95% CI0.64-0.83). While the area under ROC curve for predicting death was NLCR(0.73),which was lower than CURB-65 score(0.76)and neutrophil count(0.74).(10) The percentage of patients death within 30 days reaching clinical stability within 72 h or clinical stability was higher than 90% and the former is higher than the later.Conclusion:(1) As CURB- 65 score increase, the percentage of CAP patients deterioration and death showed a trend of increase.(2) NLCR>10 was related with CURB-65 score and deterioration and death, which prompt NLCR can be used as an indicators for prognosis of severity classification and clinical outcome of CAP patients.(3) The predict value of NLCR for deterioration and death of CAP patients is higher than CURB-65 score.The combination of NLCR and CURB-65 score can improve the accuracy.(4) The prognosis capacity of NLCR for 28 days death in patients with community acquired pneumonia was not better than CURB-65 score and neutrophil count.(5)The percentage of patients death reaching clinical stability within 72 h or clinical treatment failure was higher than 90% and the former is higher than the later.