الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Sepsis is a clinical syndrome that complicates severe infection and is characterized by systemic inflammation and widespread tissue injury. In this syndrome, tissues remote from the original insult display the cardinal signs of inflammation, including vasodilation, increased microvascular permeability, and leukocyte accumulation. Sepsis is among the most common reasons for admission to intensive care units (ICUs) throughout the world.(1) Advances in medical technologies, the increasing use of immunosuppressive agents and improvement in mean age have contributed to the exponential increase in the incidence of sepsis.(4)
Culturing microorganisms is the most definitive way to confirm bacterial infections. Unfortunately, this gold standard is time consuming and may be influenced by several factors including previous antibiotic usage. Currently used conventional infection markers such as the CRP level, the WBC count and the erythrocyte sedimentation rate ESR have relatively poor capacity in distinguishing patients with bacterial infections versus patients with non-bacterial infections. Increasing the diagnostic yield possibly lies in the combination of well-known parameters or the introduction of new markers.(130)
Evidence is growing that the Neutrophil/Lymphocyte count ratio (NLCR) is useful in the prediction of survival in various clinical settings. The value of the NLCR was previously explored in patients with lung cancer, patients with colorectal cancer and patients with liver transplantation for primary hepatocellular carcinoma, and the values of NLCR correlated well with overall and cancer-specific survival. (111,118,119,132)
The aim of this study is to investigate whether serial changes in circulating neutrophil and lymphocyte counts within peripheral blood could correlate with changes in the clinical course of sepsis and severe sepsis patients and whether CD4/CD8 cell ratio could be a predictor marker for the development of multi organ failure in those patients.
Patients and methods
The study was carried out on 40 adult patient of both sex, who fulfilled the inclusion criteria(123) (age>18, presence of SIRS, identified source of infection and evidence of organ dysfunction, hypoperfusion or hypotension) and exclusion criteria (124-126) (hematological disease, chemotherapy or glucocorticoids medications, stressful conditions as trauma, burn, surgical, malignant and pregnant patients)and were admitted to the Critical Care Medicine department in Alexandria Main University Hospital. Patients were treated according to the standard basic lines of treatment including (69) (Keeping patent airway, adequate breathing and maintenance of euvolemia by intravenous fluids, and antibiotics).
Then patients were categorized into two groups of minimal number of 15 patients according to the sample size calculation:
1- Group (A) Sepsis group 25 patients.
2- Group (B) Severe sepsis group 15 patients
Measurement
Daily APACHE II score, SOFA score, CRP, Serum lactate, WBCs, Neutrophil count, Lymphocyte count and calculation of NLCR. And on admission serum procalcitonin and CD4/CD8 cell ratio were measured.
Correlations between all these parameters and NLCR were done on admission and on the 7th day of the study.
Correlations between CD4/CD8 on admission and SOFA score on 7th day was done.
Results:
The study showed that NLCR values were more strongly significant in patients with sepsis and severe sepsis than the values of classical parameters; such as CRP, WBCs, serum lactate, neutrophelia and lymphocytopenia. With more significant increase in severe sepsis group than sepsis group, Moreover, NLCR values correlated strongly (p < 0.001) with such parameters, both on admission and at the end of 7 days which indicates that it could be used as a marker and parameter of sepsis and severe sepsis.
The ability of the NLCR, compared with traditional parameters, to predict clinical course assessed by APACHE II score and SOFA score in patients with sepsis and severe sepsis in ICU has been shown in the present study. The study showed that the AUC of the NLCR Receiver Operating Characteristic (ROC) curve was significantly higher than that of conventional infection markers, including the CRP, serum lactate, WBCs, neutrophil count, lymphocyte count levels but lower than that of procalcitonin. In addition, the sensitivity and specificity of NLCR in the present study were 88.0% and 75.0% respectively with positive and negative predictive value of 87.5% and 75.0% respectively. The NLCR thus proved to be a simple infection marker with discriminatory capacity in predicting clinical course and prognosis in infectious ICU admissions
We tried to find the relationship between outcome and CD4/CD8 cell ratio, It was found that CD4/CD8 could provide valuable information regarding prediction of mortality and development of organ failure. So it can be used as a prognostic marker.
The present study showed that survived patients were associated with statistically higher CD4/CD8 ratios than those found in patients who died. Moreover, there was a significant negative correlation between CD4/CD8 ratio on admission and development of organ failure assessed by the SOFA score.