Abstract
BackgroundThe impact of neutropenia in critically ill immunocompromised patients admitted in a context of acute respiratory failure (ARF) remains uncertain. The primary objective was to assess the prognostic impact of neutropenia on outcomes of these patients. Secondary objective was to assess etiology of ARF according to neutropenia.MethodsWe performed a post hoc analysis of a prospective multicenter multinational study from 23 ICUs belonging to the Nine-I network. Between November 2015 and July 2016, all adult immunocompromised patients with ARF admitted to the ICU were included in the study. Adjusted analyses included: (1) a hierarchical model with center as random effect; (2) propensity score (PS) matched cohort; and (3) adjusted analysis in the matched cohort.ResultsOverall, 1481 patients were included in this study of which 165 had neutropenia at ICU admission (11%). ARF etiologies distribution was significantly different between neutropenic and non-neutropenic patients, main etiologies being bacterial pneumonia (48% vs 27% in neutropenic and non-neutropenic patients, respectively). Initial oxygenation strategy was standard supplemental oxygen in 755 patients (51%), high-flow nasal oxygen in 165 (11%), non-invasive ventilation in 202 (14%) and invasive mechanical ventilation in 359 (24%). Before adjustment, hospital mortality was significantly higher in neutropenic patients (54% vs 42%; p = 0.006). After adjustment for confounder and center effect, neutropenia was no longer associated with outcome (OR 1.40, 95% CI 0.93–2.11). Similar results were observed after matching (52% vs 46%, respectively; p = 0.35) and after adjustment in the matched cohort (OR 1.04; 95% CI 0.63–1.72).ConclusionNeutropenia at ICU admission is not associated with hospital mortality in this cohort of critically ill immunocompromised patients admitted for ARF. In neutropenic patients, main ARF etiologies are bacterial and fungal infections.
Highlights
Therapeutic advances in oncology and hematology have led to improved survival in patients with cancer [1,2,3], in the sickest subgroups of patientsMokart et al Ann
In a recent multicenter observational study including 289 critically ill neutropenic cancer patients, the hospital mortality rate was 55%, neutropenia was not associated with outcome after adjustment for confounder [10]
Independent factors associated with hospital mortality were age, allogeneic hematopoietic stem cell transplantation (HSCT), invasive mechanical ventilation, RRT, microbiologic documentation; whereas, neutropenic enterocolitis was associated with survival
Summary
Therapeutic advances in oncology and hematology have led to improved survival in patients with cancer [1,2,3], in the sickest subgroups of patientsMokart et al Ann. Prognostic impact of neutropenia remains controversial, in high-risk situations such as ARF, as there are sparse data on critically ill immunocompromised population [7,8,9,10,11]. A standardized approach (the DIRECT approach) can be used to assess the cause of ARF [13,14,15] Using this tool, previous studies suggest neutropenic patients with ARF have a high risk of bacterial or fungal infection when compared to other immune defects [15]. The impact of neutropenia in critically ill immunocompromised patients admitted in a context of acute respiratory failure (ARF) remains uncertain. Secondary objective was to assess etiology of ARF according to neutropenia
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