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Evaluation of White Blood Cell Count, Neutrophil Percentage, and Elevated Temperature As Predictors of Bloodstream Infection in Burn Patients

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Evaluation of White Blood Cell Count, Neutrophil Percentage, and Elevated Temperature As Predictors of Bloodstream Infection in Burn Patients ORIGINAL ARTICLE Evaluation of White Blood Cell Count, Neutrophil Percentage, and Elevated Temperature as Predictors of Bloodstream Infection in Burn Patients Clinton K. Murray, MD; Roselle M. Hoffmaster, MD; David R. Schmit, BS; Duane R. Hospenthal, MD, PhD; John A. Ward, PhD; Leopoldo C. Cancio, MD; Steven E. Wolf, MD Objective: To investigate whether specific values of or cultures from which microorganisms were recovered. Or- changes in temperature, white blood cell count, or neu- ganisms that were recovered from blood cultures in- trophil percentage were predictive of bloodstream infec- cluded 80 that were gram negative, 54 that were gram tion in burn patients. positive, 3 that were mixed gram positive/gram nega- tive, and 3 yeasts. Although white blood cell count and Design: Retrospective review of electronic records. neutrophil percentage at the time of the culture were sta- tistically different between patients with and patients with- Setting: Intensive care center at the US Army Institute out bloodstream infection, receiver operating character- of Surgical Research Burn Center. istic curve analysis revealed these values to be poor discriminators (receiver operating characteristic curve Patients: Burn patients with blood cultures obtained from area=0.624). Temperature or alterations in tempera- 2001 to 2004. ture in the preceding 24-hour period did not predict pres- Main Outcome Measures: Temperature recorded at ence, absence, or type of bloodstream infection. the time blood cultures were obtained; highest tempera- ture in each 6-hour interval during the 24 hours prior to Conclusions: Temperature, white blood cell count, neu- this; white blood cell count and neutrophil percentage trophil percentage, or changes in these values were not at the time of obtaining the blood culture and during the clinically reliable in predicting bloodstream infection. Fur- 24 hours preceding the blood culture; demographic data; ther work is needed to identify alternative clinical para- and total body surface area burned. meters, which should prompt blood culture evaluations in this population. Results: A total of 1063 blood cultures were obtained from 223 patients. Seventy-three people had 140 blood Arch Surg. 2007;142(7):639-642 NFECTION REMAINS THE MAJOR or ventilator-associated pneumonia, and cause of death among patients 38.3°C for intensive care unit (ICU) in- with burns.1 Delays in treating in- fection.4-8 In surgical ICUs, 93% of pa- fections have been associated with tients meet the definition of systemic in- inferior outcomes, necessitating flammatory response system sometime Ithe establishment of parameters that alert during their admission, which questions physicians to the potential presence of an the utility of temperature and WBC counts infection.2,3 Temperature along with labo- (2 of the criteria for systemic inflamma- ratory parameters such as white blood cell tory response system) as clinical para- (WBC) count and neutrophil percentage meters that assess for underlying infec- or changes in these values are used as tion.9 There is conflicting data as to the markers of probable infection and often utility of these parameters in burn, surgi- trigger further evaluation. White blood cell cal, and medical patients.10-13 A recent pro- Author Affiliations: Brooke counts greater than 12ϫ103 cells/mm3 or spective study revealed that routine post- Army Medical Center, Fort Sam less than 4ϫ 103 cells/mm3 are fre- operative body temperature elevations Houston, Texas (Drs Murray, quently used as laboratory markers por- were not predictive of infection.14 Hoffmaster, Hospenthal, tending possible underlying infectious pro- Those undergoing therapy for burns of- Cancio, and Wolf); University cesses.4 Temperature elevations of ten have temperature and WBC count al- of Texas Health Science Center at San Antonio, San Antonio importance are variably defined as 38°C terations due to infectious and noninfec- (Mr Schmit and Dr Wolf); and for systemic inflammatory response sys- tious etiologies. In our study, we sought US Army Institute of Surgical tem, 38.3°C for fever of unknown infec- to investigate whether temperature, WBC Research, Fort Sam Houston tion, 38.3°C or 38°C for more than 1 hour count, and neutrophil percentage at the (Drs Cancio and Wolf). for neutropenic fevers, 38°C for hospital- time cultures were obtained or changes (REPRINTED) ARCH SURG/ VOL 142 (NO. 7), JULY 2007 WWW.ARCHSURG.COM 639 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 Pearson ␹2 test was used to evaluate categorical values, and the Table 1. Study Population Characteristics Mann-Whitney test was used to assess noncategorical values. A 1-way nonparametric analysis of variance was used to dis- Patients With Patients With close a difference in total body surface area burned or tempera- Bacteria-Positive Bacteria-Negative ture at the time of blood culture based on the type of bacteria Blood Culture Blood Culture identified (none, gram positive, gram negative [but not mixed], Characteristic (n = 73) (n = 150) or yeast) because of small numbers. Statistical significance was Mean age, ya 43 37 set at PϽ.01. Men, %b 93 80 TBSA burned, %c 42.4 28.2 No. of deaths (%)d 20 (27) 12 (8) RESULTS Abbreviation: TBSA, total body surface area. During the study period, 223 patients were admitted to a P = .03. Independent samples t test. b P = .02. ␹2 Contingency test. the US Army Institute of Surgical Research ICU, meet- c P Ͻ .001. Mann-Whitney test. ing criteria for evaluation, and a total of 1063 blood cul- d P Ͻ .001. ␹2 Contingency test. ture sets were obtained (Table 1). Older individuals (47 years old vs 37 years; P=.03) with greater total body sur- face area burned (P=.001) had more positive blood cul- tures, but initial maximum temperatures were not dif- Table 2. Most Recovered Bacteria ferent between those with and those without bloodstream by Blood Culture and Patient infections. More extensive total body surface area burned was more predictive of gram-negative (PϽ.001) but not No. of Blood No. of Ͼ Bacteria Cultures Patients gram-positive (P .05) bloodstream infection. Seventy- three patients who had blood cultures obtained (32% of Pseudomonas aeruginosa 48 19 admitted patients) had microorganisms recovered in 140 Coagulase-negative Staphylococcusa 20 19 Klebsiella pneumoniae 19 14 blood cultures (13% of blood cultures). Gram-negative Staphylococcus aureus 13 9 bacteremia was most commonly detected, with 80 cul- Acinetobacter baumannii 85tures having gram-negative bacteria identified and 54 cul- tures having gram-positive bacteria identified (Table 2). a No patient had more than 1 coagulase-negative Staphylococcus-positive Three cultures were mixed with gram-positive and gram- blood culture in a 72-hour period. negative bacteria, and 3 cultures produced yeasts (Can- dida albicans [n=2] and Candida tropicalis [n=1]). No clinically significant anaerobic bacteria were isolated. in these values in the 24 hours prior could effectively The temperature at the time of obtaining the blood predict positive blood cultures or etiology of blood- culture along with the preceding highest temperature for stream infections in an ICU burn population. each 6-hour interval in the previous 24 hours is shown in Table 3. White blood cell count and neutrophil per- METHODS centage at the time of obtaining the blood culture and the values 24 hours preceding the culture are also pre- An electronic medical records review was performed to iden- sented in Table 3. Temperature and WBC count at the tify patients with burns admitted from 2001 through 2004 to time of obtaining the blood culture were not predictive the US Army Institute of Surgical Research ICU. All patients of bloodstream infection. In addition, temperature at the who underwent blood culture were screened for the presence time of obtaining the blood culture was not predictive or absence of growth from the blood culture bottles. Because of the type of bacteremia, either gram negative or gram of access difficulty in most ICU burn patients, usual practice positive. Neutrophil percentage at the time of obtaining was to obtain blood cultures through central venous cath- the blood culture was predictive of bloodstream infec- eters, which are changed every 3 days, or arterial catheters, which tion (independent sample t test, PϽ.001); however, the are changed every 7 days. Indications for cultures typically in- difference in means between the presence or absence of clude elevated temperatures, follow-up blood culture of pre- viously bacteremic patients, and a clinician’s impression that bloodstream infection was only 3.1% (bacteremia [83.2%] the patient had bacteremia manifested by unexplained hypo- vs no bacteremia [80.1%]). By logistic regression, tem- tension or other organ deterioration, for example. Patient data perature was not predictive of bloodstream infection, but included in this study were age, sex, total body surface area WBC count and neutrophil percentage at the time of ob- burned, and mortality. For each blood culture obtained, the tem- taining the blood culture were predictive of blood- perature immediately preceding the collection of blood as well stream infection. However, receiver operating charac- as the highest temperature in each 6-hour interval of the pre- teristic curve analysis determined these parameters to be vious 24 hours was recorded. White blood cell count and neu- poor discriminators (area under the receiver operating trophil percentage (the differential most reflective of a bacte- characteristic curve=0.624; 95% confidence interval, rial or fungal infectious process) at the time nearest the blood 0.569-0.679; PϽ.001) (Figure). Nine blood cultures were culture and 24 hours prior to the culture were included in the evaluation. All blood cultures submitted within 2 hours of each associated with temperature recordings at the time of col- other were grouped and evaluated as a single data point. lection of 36.1°C or less, 2 of which revealed the pres- Logistic regression analysis was performed to compare the ence of bacteria.
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