Is Neutrophil-Lymphocyte Count Ratio a Better Indicator of Sepsis with Gram-positive Bacterial Infection?

BACKGROUND: Sepsis is the main cause of death in infectious diseases that can be caused by gram-negative or gram-positive bacteria. Definitive therapy for sepsis is antibiotics, depending on blood culture results even though it takes time for bacterial growth. Neutrophil-lymphocyte count ratio (NLCR) is a laboratory parameter that can predict bacterial infection in sepsis patients. NLCR is time-and-cost-effective and easy-to-use in daily practice, in sepsis patients infected with gram-negative, gram-positive, and no bacterial growth based on blood culture results. MATERIALS AND METHODS: This was a comparative study of NLCR and the result of blood culture from sepsis patients. Subjects were obtained from the medical records of patients admitted to our hospital from January 2019 to May 2019. Patients aged over 18 years who were diagnosed with sepsis and had blood culture information were included. Patients with hematological disorder and malignancy were excluded. Sepsis data consisted of gender, age, source of infection, comorbidity, NLCR, and blood culture results. RESULTS: Ninety-four sepsis subjects met the inclusion criteria, and fifty-one subjects (54.25%)-33 subjects (35.10%) with gram-negative bacterial infection and 18 subjects (19.15%) with gram-positive bacterial infection-were included in the analysis due to the completeness of the data. The median NLCR (IQR) was 17.8 (14.3-30.7) in gram-negative, 31.5 (26.3-95.0) in gram-positive, and 22.8 (15.67-22.75) in no bacterial growth (p = 0.001). CONCLUSION: NLCR can distinguish gram-negative and gram-positive bacterial infections. It also can predict the possibility of pathogenic bacteria that cause sepsis. HOW TO CITE THIS ARTICLE: Sumardi U, Prihardianti DR, Sudjana P. Is Neutrophil-Lymphocyte Count Ratio a Better Indicator of Sepsis with Gram-positive Bacterial Infection? Indian J Crit Care Med 2021;25(7):795-799.

Inverse relationship of serum hepcidin levels with CD4 cell counts in HIV-infected patients selected from an Indonesian prospective cohort study.

BACKGROUND: Distortion of iron homeostasis may contribute to the pathogenesis of human immunodeficiency virus (HIV) infection and tuberculosis (TB). We studied the association of the central iron-regulatory hormone hepcidin with the severity of HIV and the association between hepcidin and other markers of iron homeostasis with development of TB. METHODS: Three groups of patients were selected from a prospective cohort of HIV-infected subjects in Bandung, Indonesia. The first group consisted of HIV-infected patients who started TB treatment more than 30 days after cohort enrollment (cases). The second group consisted of HIV-infected patients who were matched for age, gender and CD4 cell count to the cases group (matched controls). The third group consisted of HIV-infected patients with CD4 cell counts above 200 cells/mm(3) (unmatched controls). Iron parameters including hepcidin were compared using samples collected at cohort enrollment, and compared with recently published reference values for serum hepcidin. RESULTS: A total of 127 HIV-infected patients were included, 42 cases together with 42 matched controls and 43 unmatched controls. Patients with advanced HIV infection had elevated serum hepcidin and ferritin levels. Hepcidin levels correlated inversely with CD4 cells and hemoglobin. Cases had significantly higher hepcidin and ferritin concentrations at cohort enrollment compared to matched controls, but these differences were fully accounted for by the cases who started TB treatment between day 31 and 60 after enrollment. Hepcidin levels were not different in those with or without hepatitis C infection. CONCLUSION: Iron metabolism is distorted in advanced HIV infection with CD4 cell counts correlating inversely with serum hepcidin levels. High serum hepcidin levels and hyperferritinemia were found in patients starting TB treatment shortly after cohort enrollment, suggesting that these parameters have a predictive value for development of manifest TB in HIV-infected patients.

Evidence for endemic chikungunya virus infections in Bandung, Indonesia.

Chikungunya virus (CHIKV) is known to cause sporadic or explosive outbreaks. However, little is known about the endemic transmission of CHIKV. To ascertain the endemic occurrence of CHIKV transmission, we tested blood samples from patients with a non-dengue febrile illness who participated in a prospective cohort study of factory workers in Bandung, Indonesia. From August 2000 to June 2004, and September 2006 to April 2008, 1901 febrile episodes occurred and 231 (12.2%) dengue cases were identified. The remaining febrile cases were evaluated for possible CHIKV infection by measuring anti-CHIKV IgM and IgG antibodies in acute and convalescent samples. Acute samples of serologically positive cases were subsequently tested for the presence of CHIKV RNA by RT-PCR and/or virus isolation. A total of 135 (7.1%) CHIKV infections were identified, providing an incidence rate of 10.1/1,000 person years. CHIKV infections were identified all year round and tended to increase during the rainy season (January to March). Severe illness was not found and severe arthralgia was not a prominently reported symptom. Serial post-illness samples from nine cases were tested to obtain a kinetic picture of IgM and IgG anti-CHIKV antibodies. Anti-CHIKV IgM antibodies were persistently detected in high titers for approximately one year. Three patients demonstrated evidence of possible sequential CHIKV infections. The high incidence rate and continuous chikungunya cases in this adult cohort suggests that CHIKV is endemically transmitted in Bandung. Further characterization of the circulating strains and surveillance in larger areas are needed to better understand CHIKV epidemiology in Indonesia.

Virological failure and drug resistance during first line anti-retroviral treatment in Indonesia.

The virological response and development of drug resistance during first-line anti-retroviral treatment (ART) were studied in Indonesia where the majority of patients infected with HIV have a history of injecting drug use, which is often linked with lower treatment adherence and development of drug-resistance. As many as 575 patients starting ART between September 2007 and March 2010 in Hasan Sadikin Hospital Bandung were followed prospectively. Clinical and laboratory monitoring was performed every 6 months. Plasma samples with HIV-RNA ≥ 400 copies/ml were examined for drug resistance mutations. Most patients were male (72.3%), 59.7% had a history of injecting drug use, and the median CD4+ cells count before start of ART was 35 cells/mm(3) (IQR 10-104). From 438 HIV patients with HIV-RNA measurements, 40 (9.1%) subjects had HIV-RNA ≥ 400 copies/ml after 24 weeks (median follow-up 16 (IQR 8-25) months). Of these failing patients 16 (47%) subjects had drug resistance mutations, predominantly M184V (35.3%), Y181C (23.5%), K103N (11.7%), and TAMs (11.7%). A history of treatment discontinuation ≥ 1 month, reported by 5.3% (23) of patients, was strongly associated with virological failure (adjusted OR 12.64, 95% CI 4.51-35.41); and a history of injecting drug use was not (OR 0.75, 95% CI 0.38-1.46). This is the largest and most systematic evaluation of virological response to first line ART in Indonesia. Patients in this cohort responded well to first line ART, with low rates of virological failure and drug resistance. A history of injecting drug use should not be a reason to withhold ART in this setting.

Response to first-line antiretroviral treatment among human immunodeficiency virus-infected patients with and without a history of injecting drug use in Indonesia.

BACKGROUND: There is a common belief that injecting drug use (IDU) is associated with lower uptake, retention and success of antiretroviral treatment (ART) in human immunodeficiency virus (HIV)-infected patients. We examined this in an Indonesian setting, where IDU is the main risk factor for HIV infection. METHODS: Patient characteristics and response to ART were recorded for all patients diagnosed with HIV infection in the referral hospital for West Java (40 million people). Kaplan-Meier estimates and Cox's regression were used to compare mortality, loss to follow-up and virological failure between patients with and without a history of IDU. RESULT: A total of 773 adult HIV patients (81.9% IDUs) presented between January 1996 and April 2008. IDUs had a median CD4 cell count of 33 [interquartile ratio (IQR), 12-111] cells/mm(3) compared to 84 (IQR, 28-224) cells/mm(3) in non-IDUs. Among patients with a history of IDU, 87.7% were coinfected with hepatitis C (HCV). Mortality was associated strongly with CD4 count; after 6 months of ART, 18.3, 20.3, 7.1 and 0.7% of patients with CD4 cell counts <25, 25-99, 100-199, respectively, > or =200/mm(3) had died (P < 0.0001). Mortality [adjusted for CD4; hazard ratio (HR) = 0.65; 95% confidence interval (CI) 0.35-1.23], loss to follow-up (HR = 0.85, 95% CI 0.51-1.41) and virological failure (HR = 0.47, 95% CI 0.19-1.13) were not significantly different in IDUs and non-IDUs. CONCLUSION: Intravenous drug users (IDUs) in Indonesia with HIV/acquired immune deficiency syndrome tend to have more advanced disease but respond similarly to non-IDUs to antiretroviral therapy.

Challenges in delivering HIV-care in Indonesia: experience from a referral hospital.

HIV in Indonesia is strongly associated with injecting drug use (IDU), and surrounding stigma and lack of knowledge reduce accessibility of services. Uptake of HIV-testing is low and many patients present with advanced AIDS. A comprehensive evaluation was made of HIV-services provided between 2006 and 2008 in a referral hospital in West-Java, the province with the highest burden of HIV in Indonesia. A total of 826 HIV-positive patients, mostly infected through IDU (73.9%), presented between 2006 - 2008. Targeted screening and provider-initiated testing and counseling (PITC) led to earlier HIV-diagnosis. Operational research helped optimize diagnosis and treatment of important disease complications. Systematic monitoring of treatment response, and collaboration with other providers, methadone maintenance program and prison help improve treatment outcome. Over the last three years, the number of individuals tested and treated for HIV increased approximately two-fold and six-month mortality decreased from 13.6% to 7.5%. Loss to follow-up was 12.2% at six months. Significant progress has been made in delivering HIV-care in West-Java through operational research, systematic treatment monitoring, and the use of simple indicators to evaluate the quantity and quality of care.

Epidemiology of dengue and dengue hemorrhagic fever in a cohort of adults living in Bandung, West Java, Indonesia.

A prospective study of dengue fever (DF) and dengue hemorrhagic fever (DHF) was conducted in a cohort of adult volunteers from two textile factories located in West Java, Indonesia. Volunteers in the cohort were bled every three months and were actively followed for the occurrence of dengue (DEN) disease. The first two years of the study showed an incidence of symptomatic DEN disease of 18 cases per 1,000 person-years and an estimated asymptomatic/ mild infection rate of 56 cases per 1,000 person-years in areas of high disease transmission. In areas where no symptomatic cases were detected, the incidence of asymptomatic or mild infection was 8 cases per 1,000 person-years. Dengue-2 virus was the predominant serotype identified, but all four serotypes were detected among the cohort. Four cases of DHF and one case of dengue shock syndrome (DSS) were identified. Three of the four DHF cases were due to DEN-3 virus. The one DSS case occurred in the setting of a prior DEN-2 virus infection, followed by a secondary infection with DEN-1 virus. To our knowledge, this is the first report of a longitudinal cohort study of naturally acquired DF and DHF in adults.