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Thank you for carefully addressing all the raised points in your revision. I am pleased to confirm that your article is now accepted for publication. Congratulations on your excellent work!
Clear and unambiguous.
Original primary research.
All underlying data have been provided; Conclusions are well stated.
No further concern.
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Clear, unambiguous, providing background context.
Original research, rigorously carried out. Methods are clearly described.
Meaningful conclusions.
As regards the missing references, contributing to focus on the paper's subject:
1) Buonacera A. et al. (Int J Mol Sci 2022) should be acknowledged, as requested in one of my previous reports, to emphasize the multitasking diagnostic potential of NLR.
2) Li Y. et al. BMC Pediatrics 2025 should be acknowledged because it explored in children the increased diagnostic power of combining several biomarkers to diagnose bloodstream infections. This Reviewer understands that retrospective expansion of biomarker datasets is methodologically unfeasible in the present study, but this is not in contrast with discussing and acknowledging in the Discussion data from other Authors, fitting with the purpose, even to correctly drive future research.
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors are in agreement that they are relevant and useful.
**PeerJ Staff Note:** Please ensure that all review, editorial, and staff comments are addressed in a response letter and that any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
The authors have adequately addressed my comments. However, correlation analysis in Table 6 was done using Pearson correlation despite the authors stating the data were skewed as revealed by the Shapiro-Wilk test. Therefore, this must be repeated using Spearman's test.
I would highly encourage the authors to improve their knowledge of statistics for their future studies.
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Literature references provided sufficient field background/context.
Professional article structure, figures, and tables. Raw data shared.
Self-contained with relevant results to hypotheses.
Original primary research within the Aims and Scope of the journal.
Research question well defined, relevant & meaningful. It is stated how research fills an identified knowledge gap.
Rigorous investigation performed to a high technical & ethical standard.
Methods described with sufficient detail & information to replicate.
Impact and novelty assessed.
All underlying data have been provided; they are robust, statistically sound, & controlled.
Conclusions are well stated, linked to the original research question & limited to supporting results.
Lines 94-96 (track changes version) should incorporate references by de Jager 2012 and Cataudella 2017. This is because these references were published earlier than the one cited (Manohar et al., 2018).
Reference by Li et al. 2025 (see my previous report) is missing in the reference list and must be both acknowledged and commented.
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-The manuscript must be reviewed for language by a professional service.
-I think the title must be rewritten to replace "auxiliary diagnosis" with "supportive marker/index" or anything to that effect.
-A high AUC (0.95) with modest sensitivity (0.72) is unusual.
-You cannot say "early" in a retrospective, cross-sectional study. It is unclear when the blood samples were collected.
-The Introduction must be made up of several paragraphs: BSI, NLR, and the aim of the study.
-The BSI diagnostic criteria were defined according to the BSI diagnostic criteria issued by the former Ministry of Health" - reference.
-Paragraphs in scientific papers are not written in numbered bullet point (e.g., methods, conclusion... etc.).
-What normality test was used?
-If the authors say NLR is better than WBC count then Figure 1 should show WBC curve as well. The Figure must also show AUC, P value, sensitivity, specificity, PPV, and NPV. Basically the same data in Table 8 and more.
-Every table must have a footnote explaining abbreviations and statistical tests used.
-Why was data in Table 2 not presented as a comparison between the two groups?
-Table 4 should be presented earlier.
-Table 7 must show this model was adjusted for what variables.
-The authors must perform correlation analysis of BSI with demographic, lab, and clinical variables and the findings must be presented in a Table before the regression data.
Li et al. in this paper titled “The value of neutrophil-to-lymphocyte ratio in the auxiliary diagnosis of elderly community-acquired bloodstream infections a retrospective study” tested the diagnostic power fo NLR in community acquired systemic infections. Besides NLR, Authors showed data on Leukocyte index, but a comparison with other indexes (PLR, MLR, SII and so on) would provide further insights to strengthen the individual diagnostic power of emerging tools in this field. Overall, NLR should probably be considered the most popular and widely tested tool in several diseases somehow linked to an inflammatory process (see for reference Buonacera A. et al., Int J Mol Sci 2022).
Authors tested the diagnostic power of NLR in community acquired systemic infections.
Authors should evaluate their findings considering the following items 1 and 2, while items 3 and 4 are suggestions for assessing further results from their data.
1. NLR was found to be a poweful prognostic predictor in patients with community acquired pneumonia (CAP) (De Jager C.P. et al. Plos One 2012, even in older patients (Cataudella E. et al., J Am Geriatr Soc 2017). These 2 references should be commented and acknowledged.
2. Among inflammatory and infectious systemic processes, NLR was helpful together with CRP as prognostic predictor in Covid-19 patients (Regolo M. et al., J Clin Med 2022), with an inverse relationship with PaO2/FiO2, a recognized marker of respiratory failure (Regolo M. et al., J Clin Med 2023). In these patients, PaO2/FiO2 behaviour is under control of the interplay between age, neutrophils, lymhocytes and CRP (Regolo M. et al., J Clin Med 2023). Please comment and acknowledge these 2 references.
3. Can Authors provide ROC curve for Leukocyte index?
4. Can Authors provide any comparisons of NLR with other well recognized inflammatory biomarkers?
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors are in agreement that they are relevant and useful.
This research report d'elsa with a sample of >60 yrs. patients with blood infections, but the data on 58 cases are not split further in other age groups. Different pathogenic bacteria were responsible, and we do not know which treatment the patients received and what was the outcome. Sex and other variables are not specified, since responses to sepsis may differ according to sex. The bottom line is that neutrophils increase, some cases show lymphocyte decreased but NLR fared much better to classify cases with bloodstream bacterial infections, and a cut-off of 8 was proposed, despite a less pronounced inflammatory neutrophil response in agenzia subjects
Small sample from a single center may be based, it should be acknowledged
Not very informative due to small sample side and lack of comparison with other indexes.
Not very new, it confirm previous findings.
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