Persistent lymphopenia is a risk factor for ICU-acquired infections and for death in ICU patients with sustained hypotension at admission

Abstract

Background: Severely ill patients might develop an alteration of their immune system called post-aggressive immunosuppression. We sought to assess the risk of ICU-acquired infection and of mortality according to the absolute lymphocyte count at ICU admission and its changes over 3 days.

Methods: Adults in ICU for at least 3 days with a shock or persistent low blood pressure were extracted from a French ICU database and included. We evaluated the impact of the absolute lymphocyte count at baseline and its change at day 3 on the incidence of ICU-acquired infection and on the 28-day mortality rate. We categorized lymphocytes in 4 groups: above 1.5 × 10³ cells/µL; between 1 and 1.5 × 10³ cells/µL; between 0.5 and 1 × 10³ cells/µL; and below 0.5 × 10³ cells/µL.

Results: A total of 753 patients were included. The median lymphocyte count was 0.8 × 10³ cells/µL [0.51-1.29]. A total of 174 (23%) patients developed infections; the 28-day mortality rate was 21% (161/753). Lymphopenia at admission was associated with ICU-acquired infection (p < 0.001) but not with 28-day mortality. Independently of baseline lymphocyte count, the absence of lymphocyte count increase at day 3 was associated with ICU-acquired infection (sub-distribution hazard ratio sHR: 1.37 [1.12-1.67], p = 0.002) and with 28-day mortality (sHR: 1.67 [1.37-2.03], p < 0.0001).

Conclusion: Lymphopenia at ICU admission and its persistence at day 3 were associated with an increased risk of ICU-acquired infection, while only persisting lymphopenia predicted increased 28-day mortality. The lymphocyte count at ICU admission and at day 3 could be used as a simple and reproductive marker of post-aggressive immunosuppression.

Keywords: Absolute lymphocyte count; ICU; Immunosuppression; Infection; Nosocomial; Shock; Survival.

Fig. 1

Flowchart

Fig. 2

Cumulative incidence curves of ICU-acquired infection a according to baseline lymphocyte count categorized in 4 classes; cumulative incidence curve of ICU-acquired infection (b) and incidence curve of death (c) according to the increase from baseline of the lymphocyte count at day 3 (increase in lymphocyte count was considered significant if greater than 0.2 × 10³ cells/µL). Numbers below each figure represent the number of patients still at risk of event at a particular time point. No patient were lost to follow-up at day 28