Predictors of Nosocomial Pneumonia in Intracerebral Hemorrhage Patients: A Multi-center Observational Study

Effectiveness of bundled care in the management of cerebral hemorrhage complicated by pulmonary infection in China: A systematic review and meta-analysis

OBJECTIVE

Aimed to systematically evaluate the therapeutic and rehabilitative effects of bundled care on patients with cerebral hemorrhage complicated by pulmonary infection in China.

METHODS

Relevant literature was retrieved from multiple databases and original studies investigated the efficacy of bundled care in managing cerebral hemorrhage complicated by pulmonary infection were included. Data analysis was conducted using Meta-analysis software (RevMan 5.3 and Stata 17.0). The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. Sensitivity analysis was performed to evaluate the robustness of the results. Funnel plot, Begg and Egger test were conducted to assess the presence of publication bias. The protocol was registered in PROSPERO (CRD42023475738).

RESULTS

Twelve studies involving 1049 patients were included in this meta-analysis. The results showed that bundled care significantly reduced the duration of antibiotic use and pulmonary infection (SMD = -0.77), reduced the duration of tracheal intubation (MD = -5.35), and shortened hospital stay (MD = -6.30). The effective rate of treatment (OR = 8.39), satisfaction degree (OR = 5.65), anxiety (MD = -4.52) and depression scores (MD = -4.38), and quality of life scores (MD = 11.75) were improved after bundled care intervention compared to routine care. Assessment of publication bias showed no significant evidence of publication bias.

CONCLUSIONS

Bundled care can significantly shorten the duration of illness treatment and hospital stay of patients with cerebral hemorrhage complicated by pulmonary infection, improve treatment effectiveness and satisfaction degree, alleviate anxiety and depression, and promote the improvement of quality of life.

Risk Factors for the Development of Pneumonia in Stroke Patients: A Systematic Review and Meta-Analysis

Pneumonia is one of the most prevalent medical complications post-stroke. It can have negative impacts on the prognosis of stroke patients. This study aimed to determine the predictors of pneumonia in stroke patients. The authors devised, reviewed, and enhanced the search strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were gathered from various electronic databases, including Medline, CINAHL, Cochrane, Embase, and Web of Science, from January 1st, 2011, to February 25th, 2024. The review encompassed studies involving patients aged 18 years and older who were hospitalized for acute stroke care. Inclusion criteria required patients to have received a clinical diagnosis of stroke, confirmed via medical imaging (CT or MRI), hospital primary diagnosis International Classification of Diseases 10th Revision discharge codes, or pathology reporting. A total of 35 studies met the criteria and were included in our pooled analysis. Among them, 23 adopted a retrospective design, while the remaining 12 were prospective. The pooled incidence of pneumonia among patients with stroke was found to be 14% (95% confidence interval = 13%-15%). The pooled analysis reported that advancing age, male gender, a history of chronic obstructive pulmonary disease (COPD), the presence of a nasogastric tube, atrial fibrillation, mechanical ventilation, stroke severity, dysphagia, and a history of diabetes were identified as significant risk factors for pneumonia development among stroke patients. Our results underscore the importance of proactive identification and management of these factors to mitigate the risk of pneumonia in stroke patients.

Distribution of bacteria and risk factors in patients with multidrug-resistant pneumonia in a single center rehabilitation ward

Stroke patients may have dysphagia and frequent aspiration increasing exposure to antibiotics and the chance of multidrug-resistant (MDR) bacteria infection. This study investigated clinical risk factors and related antibiotic use of MDR bacteria infection in stroke patients in the rehabilitation ward, hoping that it can help prevent and reduce the condition of MDR bacteria. A retrospective cohort study was conducted using the database of stroke patients with pneumonia admitted to the rehabilitation ward from January 1, 2020, to June 30, 2022. The selected stroke patients were divided into the MDR and non-MDR groups. Analyze the infection bacteria of the 2 groups. Forward logistic regression was applied to identify possible independent MDR bacteria infection risk factors. A total of 323 patients were included. The top 3 common MDR pathogens were Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Almost all Pseudomonas aeruginosa and Acinetobacter baumannii are resistant to ertapenem. National Institute of Health stroke scale at admission was associated with MDR bacteria infection pneumonia (OR [odds ratio] = 1.078, 95%CI [1.017, 1.142]). Long-term tracheotomy (OR = 2.695, 95%CI [1.232, 5.897]), hypoalbuminemia (OR = 473, 95%CI [1.318, 4.642]), and bilateral cerebral hemisphere stroke (OR = 4.021, 95%CI [2.009, 8.048]) were significant clinical risk factors of MDR pneumonia after stroke. The detection rate of MDR bacteria has increased. Understanding the distribution and drug resistance of MDR bacteria in stroke patients with pneumonia in the neurological rehabilitation ward and the related susceptibility of MDR bacteria infection is necessary. This way, the treatment plan can be adjusted more timely, avoiding the abuse of antibiotics.

Effect of Electroacupuncture on the Treatment of Pneumonia in Patients with Hypertensive Intracerebral Hemorrhage

OBJECTIVE

Pneumonia is a serious postoperative complication of hypertensive intracerebral hemorrhage (HICH), and there is no specific treatment for pneumonia. In this study, we conducted randomized controlled trials to evaluate the effects of electroacupuncture (EA) on the treatment of pneumonia in patients with HICH.

METHODS

An equal number of patients with HICH complicated with pneumonia (n = 80 in total) were randomly placed in either the EA group (EA treatment and routine basic treatment) or the control group (routine basic treatment). After 14 days of treatment, clinical symptoms and signs, blood oxygen saturation, the level of inflammatory factors, the effective rate, the scores of the Barthel Index, National Institutes of Health Stroke Scale and Glasgow Coma Scale, the hospitalization time, and expenses were compared between the groups.

RESULTS

The general information of the patients in the control and EA groups were similar. After 14 days of intervention, the patients in the EA group showed better symptom and sign scores, blood oxygen saturation levels, Barthel Index scores, Glasgow Coma Scale scores, and National Institutes of Health Stroke Scale scores than the patients in the control group. Furthermore, the EA treatment also lowered the levels of inflammatory factors and white blood cell count. Additionally, the patients in the EA group showed higher effective rates than those in the control group.

CONCLUSIONS

EA benefits the treatment of pneumonia in patients with HICH.

Procalcitonin as a biomarker of nosocomial pneumonia in aneurysmal subarachnoid hemorrhage patients treated in neuro-ICU

BACKGROUND

Nosocomial pneumonia commonly develops in aneurysmal subarachnoid hemorrhage (aSAH) patients and is associated with poor prognosis of these patients. This study is designed to verify the predictive value of procalcitonin (PCT) on nosocomial pneumonia in aSAH patients.

METHODS

298 aSAH patients received treatments in the neuro-intensive care unit (NICU) of West China hospital were included. Logistic regression was conducted to verify the association between PCT level and nosocomial pneumonia and to construct a model for predicting pneumonia. Area under the receiver operating characteristic curve (AUC) were calculated to evaluate the accuracy of the single PCT and the constructed model.

RESULTS

90 (30.2%) patients developed pneumonia during hospitalizations among included aSAH patients. Pneumonia group had higher procalcitonin level (p < 0.001) than non-pneumonia group. The mortality (p < 0.001), mRS (p < 0.001), length of ICU stay (p < 0.001), length of hospital stay (p < 0.001) were both higher or longer in pneumonia group. Multivariate logistic regression indicated WFNS (p = 0.001), acute hydrocephalus (p = 0.007), WBC (p = 0.021), PCT (p = 0.046) and C-reactive protein (CRP) (p = 0.031) were independently associated with the development of pneumonia in included patients. The AUC value of procalcitonin for predicting nosocomial pneumonia was 0.764. Composed of WFNS, acute hydrocephalus, WBC, PCT and CRP, the predictive model for pneumonia has higher AUC of 0.811.

CONCLUSIONS

PCT is an available and effective predictive marker of nosocomial pneumonia in aSAH patients. Composed of WFNS, acute hydrocephalus, WBC, PCT and CRP, our constructed predictive model is helpful for clinicians to evaluate the risk of nosocomial pneumonia and guide therapeutics in aSAH patients.

Novel machine learning models to predict pneumonia events in supratentorial intracerebral hemorrhage populations: An analysis of the Risa-MIS-ICH study

Background

Stroke-associated pneumonia (SAP) contributes to high mortality rates in spontaneous intracerebral hemorrhage (sICH) populations. Accurate prediction and early intervention of SAP are associated with prognosis. None of the previously developed predictive scoring systems are widely accepted. We aimed to derive and validate novel supervised machine learning (ML) models to predict SAP events in supratentorial sICH populations.

Methods

The data of eligible supratentorial sICH individuals were extracted from the Risa-MIS-ICH database and split into training, internal validation, and external validation datasets. The primary outcome was SAP during hospitalization. Univariate and multivariate analyses were used for variable filtering, and logistic regression (LR), Gaussian naïve Bayes (GNB), random forest (RF), K-nearest neighbor (KNN), support vector machine (SVM), extreme gradient boosting (XGB), and ensemble soft voting model (ESVM) were adopted for ML model derivations. The accuracy, sensitivity, specificity, and area under the curve (AUC) were adopted to evaluate the predictive value of each model with internal/cross-/external validations.

Results

A total of 468 individuals with sICH were included in this work. Six independent variables [nasogastric feeding, airway support, unconscious onset, surgery for external ventricular drainage (EVD), larger sICH volume, and intensive care unit (ICU) stay] for SAP were identified and selected for ML prediction model derivations and validations. The internal and cross-validations revealed the superior and robust performance of the GNB model with the highest AUC value (0.861, 95% CI: 0.793–0.930), while the LR model had the highest AUC value (0.867, 95% CI: 0.812–0.923) in external validation. The ESVM method combining the other six methods had moderate but robust abilities in both cross-validation and external validation and achieved an AUC of 0.843 (95% CI: 0.784–0.902) in external validation.

Conclusion

The ML models could effectively predict SAP in sICH populations, and our novel ensemble model demonstrated reliable robust performance outcomes despite the populational and algorithmic differences. This attempt indicated that ML application may benefit in the early identification of SAP.

Braden scale for predicting pneumonia after spontaneous intracerebral hemorrhage

OBJECTIVE

Stroke-associated pneumonia is an infection that commonly occurs in patients with spontaneous intracerebral hemorrhage and causes serious burdens. In this study, we evaluated the validity of the Braden scale for predicting stroke-associated pneumonia after spontaneous intracerebral hemorrhage.

METHODS

Patients with spontaneous intracerebral hemorrhage were retrospectively included and divided into pneumonia and no pneumonia groups. The admission clinical characteristics and Braden scale scores at 24 h after admission were collected and compared between the two groups. Receiver operating characteristic curve analysis was performed to assess the predictive validity of the Braden scale. Multivariable analysis was conducted to identify the independent risk factors associated with pneumonia after intracerebral hemorrhage.

RESULTS

A total of 629 intracerebral hemorrhage patients were included, 150 (23.8%) of whom developed stroke-associated pneumonia. Significant differences were found in age and fasting blood glucose levels between the two groups. The mean score on the Braden scale in the pneumonia group was 14.1±2.4, which was significantly lower than that in the no pneumonia group (16.5±2.6), p<0.001. The area under the curve for the Braden scale for the prediction of pneumonia after intracerebral hemorrhage was 0.760 (95%CI 0.717-0.804). When the cutoff point was 15 points, the sensitivity was 74.3%, the specificity was 64.7%, the accuracy was 72.0%, and the Youden's index was 39.0%. Multivariable analysis showed that a lower Braden scale score (OR 0.696; 95%CI 0.631-0.768; p<0.001) was an independent risk factor associated with stroke-associated pneumonia after intracerebral hemorrhage.

CONCLUSION

The Braden scale, with a cutoff point of 15 points, is moderately valid for predicting stroke-associated pneumonia after spontaneous intracerebral hemorrhage.

Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations

Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.

High Flow Nasal Cannula Decreased Pulmonary Complications in Neurologically Critically Ill Patients

Objective: Pulmonary complications could badly affect the recovery of neurological function and neurological prognosis of neurological critically ill patients. This study evaluated the effect of high-flow nasal cannula (HFNC) therapy on decreasing pulmonary complications in neurologically critically ill patients.

Patients and Methods: The patients admitted to the intensive care unit (ICU) with serious neurological disease and receiving oxygen therapy were retrospectively reviewed (Ethical No. IRB2021-YX-001). Patients were divided into the HFNC group and the conventional oxygen therapy (COT) group. We analyzed the data within these two groups, including patients’ baseline data, short-term outcomes of respiratory complications, general outcomes including hospital stay, ICU stay and mortality, and neurological functions. To analyze the relevant factors, we performed multivariable logistic regression analysis.

Results: A total of 283 patients met the criteria, including 164 cases in the HFNC group and 119 cases in the COT group. The HFNC group had remarkably less mechanical ventilation requirement with lower phlegm viscosity. Even more, ICU stay and total hospital stay were significantly shortened in the HNFC group.

Conclusion: HFNC decreased pulmonary complications in neurologically critically ill patients and improved recovery of neurological function and neurological prognosis.

Effect of Capsaicin Atomization-Induced Cough on Sputum Excretion in Tracheotomized Patients After Hemorrhagic Stroke: A Randomized Controlled Trial

Background Timely and effective removal of respiratory secretions is of great significance for tracheotomized patients. The purpose of this study is to investigate the effectiveness of capsaicin nebulization to stimulate cough to promote early clearance of respiratory secretions in tracheotomized patients after hemorrhagic stroke. Method This study implemented a randomized controlled design. Sixty-three patients who were tracheotomized following a hemorrhagic stroke completed this randomized controlled trial. In the control group, 33 cases were given a routine care after tracheotomy. In the intervention group, 30 cases were given a capsaicin solution nebulization in addition to the routine care. The daily sputum output and the number of sputum suctioning were observed. The differences in sputum viscosity, cough function, and Clinical Pulmonary Infection Score (CPIS) were compared between the two groups before and after the intervention. Vital sign changes during capsaicin nebulization and suctioning were compared between the two groups in a pilot study. Results The daily sputum output of the capsaicin intervention group was significantly higher than that of the control group (p < .05). The number of sputum suctioning of capsaicin group was less than that of the control group after intervention (p < .05). The CPIS score of the capsaicin group was lower than that of the control group (p < .05) after a 1-week intervention. Patients' heart rate, respiratory rate, and oxygen saturation during capsaicin nebulization were not statistically different from those during routine sputum suctioning (p > .05). Conclusions Capsaicin atomization-induced cough can effectively promote sputum excretion of hemorrhagic stroke patients undergoing tracheotomy and has a good safety profile. The Clinical Trial registration number of this study is ChiCTR2000037772 (http://www.chictr.org.cns). Supplemental Material https://doi.org/10.23641/asha.16821352.

Health Care-Associated Infections in a Neurocritical Care Unit of a Developing Country

BACKGROUND

Health care-associated infections (HAIs) in intensive care units (ICUs) specialized for neurocritical care (neurocritical care units [NCCUs]) are serious yet preventable complications that contribute significantly to morbidity and mortality worldwide. However, reliable data are scarcely available from the developing world. We aimed to analyze the incidence, epidemiology, microbial etiology, and outcomes of HAIs in an NCCU of a tertiary care teaching hospital in a high-income, developing country.

METHODS

In this 3-year retrospective cohort study, all patients admitted to the NCCU at the Ibn Sina Hospital in Kuwait for ≥ 2 calendar days were included. Patient demographics, hospitalization, and details of ICU-acquired infections were evaluated. Patient-related outcomes included hospital and ICU length of stay (LOS) and in-hospital mortality.

RESULTS

Among 913 patients with a total of 4921 ICU days, 79 patients had 109 episodes of HAIs. The overall incidence rate and incidence density of HAIs were 11.9/100 patients and 22.1/1000 ICU days, respectively. Multiple episodes of infection were documented in 29% of patients. The most prevalent infections were urinary tract infections (UTIs; 40/109 [37%]), bloodstream infections (30/109 [28%]), and pneumonia (16/109 [15%]). Seventy-six percent of infections were device-associated infections. A total of 158 pathogens were isolated, of which 109 were Gram-negative bacteria. Of the 40 Gram-positive bacteria, 22 were staphylococci. Seven infections were due to Clostridium difficile. There were 15 Staphylococcus aureus isolates, 47% of which were methicillin resistant. Two episodes of UTIs were due to Candida species. There were 84 Enterobacteriaceae isolates, 24% of which were extended-spectrum β-lactamase producers. All Pseudomonas aeruginosa isolates were susceptible to aminoglycosides and carbapenems. Klebsiella species were the most common pathogen (45/158 [28%]), causing pneumonia (11/33 isolates [33%]), bloodstream infections (12/37 isolates [32%]), and UTIs (16/52 isolates [31%]). One episode of bloodstream infection was due to multidrug resistant Acinetobacter baumanii which was susceptible only to colistin. Only pneumonia was independently associated with mortality, while all HAIs that occurred were significantly associated with a prolonged ICU LOS.

CONCLUSIONS

This is the first HAI surveillance study in an NCCU in Kuwait, and our results demonstrate the burden of HAIs on the neurologically injured patient, regardless of the site of infection. The high prevalence and resistant profile of HAIs in an NCCU in a developing country relative to a developed country has important implications for patient safety and emphasizes the need to strengthen collaboration between NCCU teams and infection control teams to prevent serious complications in this setting.

A meta-analysis of the clinical efficacy of Tanreqing injection combined with antibiotics vs antibiotics alone for treating pulmonary infection secondary to intracerebral hemorrhage

BACKGROUND

Pulmonary infection is the most common complication to develop after intracerebral hemorrhage (ICH). Antibiotics have certain limitations when used to treat pulmonary infection, while Tanreqing injection (TRQI) is extensively used to treat pulmonary infection as an adjuvant to antibiotics. The aim of this meta-analysis was to investigate the clinical efficacy of TRQI for the treatment of lung infection secondary to ICH.

METHODS

Randomized controlled trials (RCTs) assessing the combination of TRQI and antibiotics compared to antibiotics alone for pulmonary infection after ICH were comprehensively searched for in 7 electronic databases from their establishment to August 2020. Two independent researchers conducted the literature retrieval, screening, and data extraction. The assessment tool of Cochrane risk of bias and Review Manager 5.3 software were applied to assess the methodological quality and analyze the data, respectively.

RESULTS

Seventeen RCTs involving 1122 patients with pulmonary infection after ICH were included. Compared to antibiotics alone, the combination treatment enhanced the clinical effective rate, shortened the hospital stay, reduced the white blood cell, procalcitonin, and C-reactive protein levels, ameliorated the times to the resolution of fever, cough, and lung rales, and increased the oxygenation index. The evidence indicated that TRQI combined with antibiotics caused no adverse reactions.

CONCLUSIONS

Our study showed that the combination of TRQI and antibiotics was effective for treating pulmonary infection after ICH. However, high-quality multicenter RCTs are needed to further verify the clinical efficacy of TRQI due to the publication bias and the low methodological quality of the included RCTs.

Glycemic Gap Predicts in-Hospital Mortality in Diabetic Patients with Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

The relationship between admission hyperglycemia and intracerebral hemorrhage (ICH) outcome remains controversial. Glycemic gap (GG) is a superior indicator of glucose homeostatic response to physical stress compared to admission glucose levels. We aimed to evaluate the association between GG and in-hospital mortality in ICH.

METHODS

We retrospectively identified consecutive patients hospitalized for spontaneous ICH at the 2 healthcare systems in the Twin Cities area, MN, between January 2008 and December 2017. Patients without glycosylated hemoglobin (HbA1c) test or those admitted beyond 24 hours post-ICH were excluded. Demographics, medical history, admission tests, and computed tomography data were recorded. GG was computed using admission glucose level minus HbA1c-derived average glucose. The association between GG and time to in-hospital mortality was evaluated by Cox regression analysis. Receiver operating characteristic (ROC) analysis with the DeLong test was used to evaluate the ability of GG to predict in-hospital death.

RESULTS

Among 345 included subjects, 63 (25.7%) died during the hospital stay. Compared with survivors, non-survivors presented with a lower Glasgow coma scale score, larger hematoma volume, and higher white blood cells count, glucose, and GG levels at admission (p<0.001). GG remained an independent predictor of in-hospital mortality after adjusting for known ICH outcome predictors and potential confounders [adjusted hazard ratio: 1.09, 95% confidence interval (CI): 1.02-1.18, p = 0.018]. GG showed a good discriminative power (area under the ROC curve: 0.75, 95% CI: 0.68-0.82) in predicting in-hospital death and performed better than admission glucose levels in diabetic patients (p = 0.030 for DeLong test).

CONCLUSIONS

Admission GG is associated with the risk of in-hospital mortality and can potentially represent a useful prognostic biomarker for ICH patients with diabetes.

Exploration of Multiparameter Hematoma 3D Image Analysis for Predicting Outcome After Intracerebral Hemorrhage

BACKGROUND

Rapid diagnosis and proper management of intracerebral hemorrhage (ICH) play a crucial role in the outcome. Prediction of the outcome with a high degree of accuracy based on admission data including imaging information can potentially influence clinical decision-making practice.

METHODS

We conducted a retrospective multicenter study of consecutive ICH patients admitted between 2012-2017. Medical history, admission data, and initial head computed tomography (CT) scan were collected. CT scans were semiautomatically segmented for hematoma volume, hematoma density histograms, and sphericity index (SI). Discharge unfavorable outcomes were defined as death or severe disability (modified Rankin Scores 4-6). We compared (1) hematoma volume alone; (2) multiparameter imaging data including hematoma volume, location, density heterogeneity, SI, and midline shift; and (3) multiparameter imaging data with clinical information available on admission for ICH outcome prediction. Multivariate analysis and predictive modeling were used to determine the significance of hematoma characteristics on the outcome.

RESULTS

We included 430 subjects in this analysis. Models using automated hematoma segmentation showed incremental predictive accuracies for in-hospital mortality using hematoma volume only: area under the curve (AUC): 0.85 [0.76-0.93], multiparameter imaging data (hematoma volume, location, CT density, SI, and midline shift): AUC: 0.91 [0.86-0.97], and multiparameter imaging data plus clinical information on admission (Glasgow Coma Scale (GCS) score and age): AUC: 0.94 [0.89-0.99]. Similarly, severe disability predictive accuracy varied from AUC: 0.84 [0.76-0.93] for volume-only model to AUC: 0.88 [0.80-0.95] for imaging data models and AUC: 0.92 [0.86-0.98] for imaging plus clinical predictors.

CONCLUSIONS

Multiparameter models combining imaging and admission clinical data show high accuracy for predicting discharge unfavorable outcome after ICH.

The risk factors for the postoperative pulmonary infection in patients with hypertensive cerebral hemorrhage: A retrospective analysis

ABSTRACT

The risk factors for the pulmonary infections after hypertensive cerebral hemorrhage remains unclear. We aimed to investigate the potential risk factors for the postoperative pulmonary infection in patients with hypertensive cerebral hemorrhage.Patients with hypertensive cerebral hemorrhage undergone surgery from January 2018 to December 2019 were included. Related personal and medical information were collected. Univariate and multivariate logistic regression analyses were performed to identify the potential risk factors for the postoperative pulmonary infection.A total of 264 patients were included, and the incidence of pulmonary infection for patients with hypertensive cerebral hemorrhage after surgery was 19.70%. Escherichia coli is the most common bacteria of pulmonary infection. Multivariate regression analysis revealed that the preoperative hypoalbuminemia (OR2.89, 1.67∼4.78), tracheotomy (OR5.31, 1.24∼11.79), diabetes (OR4.92, 1.32∼9.80), preoperative GCS (OR5.66, 2.84∼11.21), and the duration of mechanical ventilation (OR2.78, 2.32∼3.61) were the independent risk factors for the pulmonary infection in patients with hypertensive cerebral hemorrhage (all P < .05).Patients with hypertensive intracerebral hemorrhage after surgery have a higher risk of postoperative pulmonary infections, and there are many related risk factors, which should be taken seriously in clinical practice.

The Magnitude of Blood Pressure Reduction Predicts Poor In-Hospital Outcome in Acute Intracerebral Hemorrhage

BACKGROUND

Early systolic blood pressure (SBP) reduction is believed to improve outcome after spontaneous intracerebral hemorrhage (ICH), but there has been a limited assessment of SBP trajectories in individual patients. We aimed to determine the prognostic significance of SBP trajectories in ICH.

METHODS

We collected routine data on spontaneous ICH patients from two healthcare systems over 10 years. Unsupervised functional principal components analysis (FPCA) was used to characterize SBP trajectories over first 24 h and their relationship to the primary outcome of unfavorable shift on modified Rankin scale (mRS) at hospital discharge, categorized as an ordinal trichotomous variable (mRS 0-2, 3-4, and 5-6 defined as good, poor, and severe, respectively). Ordinal logistic regression models adjusted for baseline SBP and ICH volume were used to determine the prognostic significance of SBP trajectories.

RESULTS

The 757 patients included in the study were 65 ± 23 years old, 56% were men, with a median (IQR) Glasgow come scale of 14 (8). FPCA revealed that mean SBP over 24 h and SBP reduction within the first 6 h accounted for 76.8% of the variation in SBP trajectories. An increase in SBP reduction (per 10 mmHg) was significantly associated with unfavorable outcomes defined as mRS > 2 (adjusted-OR = 1.134; 95% CI 1.044-1.233, P = 0.003). Compared with SBP reduction < 20 mmHg, worse outcomes were observed for SBP reduction = 40-60 mmHg (adjusted-OR = 1.940, 95% CI 1.129-3.353, P = 0.017) and > 60 mmHg, (adjusted-OR = 1.965, 95% CI 1.011, 3.846, P = 0.047). Furthermore, the association of SBP reduction and outcome varied according to initial hematoma volume. Smaller SBP reduction was associated with good outcome (mRS 0-2) in small (< 7.42 mL) and medium-size (≥ 7.42 and < 30.47 mL) hematomas. Furthermore, while the likelihood of good outcome was low in those with large hematomas (≥ 30.47 mL), smaller SBP reduction was associated with decreasing probability of severe outcome (mRS 5-6).

CONCLUSION

Our analyses suggest that in the first 6 h SBP reduction is significantly associated with the in-hospital outcome that varies with initial hematoma volume, and early SBP reduction > 40 mmHg may be harmful in ICH patients. For early SBP reduction to have an effective therapeutic effect, both target levels and optimum SBP reduction goals vis-à-vis hematoma volume should be considered.

Matrix Metalloproteinases in Acute Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) accounts for 10-30% of all strokes and affects more than one million people every year worldwide, and it is the stroke subtype associated with the highest rates of mortality and residual disability. So far, clinical trials have mainly targeted primary cerebral injury and have substantially failed to improve clinical outcomes. The understanding of the pathophysiology of early and delayed injury after ICH is, hence, of paramount importance to identify potential targets of intervention and develop effective therapeutic strategies. Matrix metalloproteinases (MMPs) represent a ubiquitous superfamily of structurally related zinc-dependent endopeptidases able to degrade any component of the extracellular matrix. They are upregulated after ICH, in which different cell types, including leukocytes, activated microglia, neurons, and endothelial cells, are involved in their synthesis and secretion. The aim of this review is to summarize the available experimental and clinical evidence about the role of MMPs in brain injury following spontaneous ICH and provide critical insights into the underlying mechanisms.

Ventilator-associated pneumonia in patients with cerebral hemorrhage: Impact on mortality and microbiological characterization

Ventilator-associated pneumonia (VAP) is a major complication among critically ill patients who depend on mechanical ventilation. Few reports have focused on intracerebral hemorrhage patients with VAP. Our main objective was to investigate the bacteria distribution characteristics and the impact of ventilator-associated pneumonia mortality in critical cerebral hemorrhage patients. This retrospective study included 89 cases of cerebral hemorrhage patients with VAP admitted to the ICU of Huashan Hospital. We used the chi-square test to compare qualitative variables and Student's t-test to compare means between groups of normally distributed quantitative variables. Multiple logistic regression analysis was used to assess mortality-independent predictors in the ICU. A total of 42% patients with cerebral hemorrhage were diagnosed with VAP in the ICU during the study period, and the mortality rate was 18%. Acinetobacter baumannii (n=58), Klebsiella pneumoniae (n=52), and Pseudomonas aeruginosa (n=21) were the most common pathogenic bacteria. Blood volume >30ml, tracheal ventilation mode and head of bed elevation were independent factors associated with increased mortality. Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the time from bleeding to intubation were other potentially important factors. While the number of infecting bacteria may not be directly related to death, it can increase antibiotic consumption and length of intensive care unit (ICU) stays. Blood volume >30ml, tracheal ventilation mode and head of bed elevation were directly related to the death of critical cerebral hemorrhage patients with ventilator-associated pneumonia.

Risk Factors for Stroke Associated Pneumonia

BACKGROUND:

Stroke patients are at high risk for stroke-associated pneumonia (SAP). If patients suffer from pneumonia their prognosis will worsen.

AIM:

To identify factors that increases the risk of SAP in stroke patients.

METHODS:

A group of 508 patients hospitalized within 5 days after the onset of stroke were enrolled prospectively.

RESULTS:

The incidence of SAP was 13.4%. Some major risk factors for SAP are: mechanical ventilation (MV) had odds ratio (OR) 16.4 (p <0.01); the National Institutes of Health Stroke Scale (NIHSS) > 15 OR 9.1 (p <0.01); the Gugging Swallowing Screen (GUSS) 0-14 OR 11.7 (p <0.01).

CONCLUSION:

SAP is a frequent complication. We identified some risk factors of SAP, especially stroke severity (NIHSS > 15), swallowing disorder (GUSS < 15) and mechanical ventilation.

Healthcare-Associated Infections in the Neurocritical Care Unit

PURPOSE OF REVIEW

This article summarizes updated data and knowledge on healthcare-associated infections in the neurocritical care unit, with a focus on central nervous system infections and systemic infectious complications in patients with acute brain disease. It also reviews the concept of brain injury-induced immune modulation, an underlying mechanism to explain why the neuro-ICU population is particularly susceptible to infections.

RECENT FINDINGS

Healthcare-associated infections in the neuro-ICU are common: up to 40 % of meningitides in the developed world are now healthcare-associated. The number of gram-negative infections is rising. New diagnostic approaches attempt to aid in the diagnosis of healthcare-associated meningitis and ventriculitis. Healthcare-associated infections in the neurocritical care unit remain a challenge for diagnosis, treatment, and prevention. Gaining a better understanding of at-risk patients and development of preventative strategies will be the goal for future investigation.

Early Predictors for Infectious Complications in Patients With Spontaneous Intracerebral Hemorrhage and Their Impact on Outcome

Background: Infectious complications (IC) commonly occur in patients with intracerebral hemorrhage (ICH) and are associated with increased length of hospitalization (LOS) and poor long-term outcome. Little is known about early ICH-related predictors for the development of IC to allow appropriate allocation of resources and timely initiation of preventive measures. Methods: We prospectively enrolled 229 consecutive patients with non-traumatic ICH admitted to the neurocritical care unit (NICU) of a tertiary care hospital. Patients were screened daily for IC. Multivariable regression models using generalized linear models were used to identify associated factors with the occurrence of IC and to study their impact on functional outcome, which was assessed using the modified Rankin Scale Score (mRS) after 3 months. Unfavorable outcome was defined as mRS ≥3. Results: The most common IC were pneumonia (n = 64, 28%) and urinary tract infection (n = 54, 24%), followed by sepsis (n = 9, 4%) and ventriculitis (n = 4, 2%). Patients with a higher admission ICH Score (>2) had higher odds to develop any IC during NICU stay (OR = 1.7, 95% CI 1.2-2.3, p = 0.02). Moreover, early-onset pneumonia (≤48 h after admission) was predictive of sepsis occurring at a later time-point (median at day 11 [IQR = 6-34 days], adjOR = 22.5, 95% CI 4.88-103.6, p < 0.001). Having at least one IC and pneumonia itself were independently associated with unfavorable 3-months outcome (adjOR = 3.0, 95% CI 1.41-6.54, p = 0.005; adjOR = 4.2, 95% CI 1.33-13.19, p = 0.015, respectively). All patients with sepsis died or had poor functional outcome. Conclusions: Infectious complications are common in ICH patients and independently associated with unfavorable outcome. An ICH Score >2 on admission and early pneumonia may help to early identify patients at high risk of IC to allocate resources and start careful surveillance.

Blood Pressure Variability Predicts Poor In-Hospital Outcome in Spontaneous Intracerebral Hemorrhage

Background and Purpose- There is increasing evidence that higher systolic blood pressure variability (SBPV) may be associated with poor outcome in patients with intracerebral hemorrhage (ICH). We explored the association between SBPV and in-hospital ICH outcome. Methods- We collected 10-years of consecutive data of spontaneous ICH patients at 2 healthcare systems. Demographics, medical history, laboratory tests, computed tomography scan data, in-hospital treatments, and neurological and functional assessments were recorded. Blood pressure recordings were extracted up to 24 hours postadmission. SBPV was measured using SD, coefficient of variation, successive variation (SV), range and 1 novel index termed functional SV. The effects of SBPV on the functional outcome at discharge were evaluated by multivariate logistic and ordinal regression analyses for dichotomous and trichotomous modified Rankin Scale categorizations, respectively. In secondary analyses, associations between SBPV, history of hypertension, and hematoma expansion were explored. Results- The analysis included 762 subjects. All 5 SBPV indices were significantly associated with the probability of unfavorable outcome (modified Rankin Scale score, 4-6) in logistic models. In ordinal models, SD, coefficient of variation, range, and functional SV were found to have a significant effect on the probabilities of poor (modified Rankin Scale score, 3-4) and severe/death (modified Rankin Scale score, 5-6) outcomes. Normotensive patients had significantly lower mean SBPV compared with the untreated-hypertension cohort for all SBPV indices and compared with treated-hypertension patients for 3 out of 5 SBPV indices. Lower mean SBPV of treated-hypertension subjects compared with untreated-hypertension subjects was only detected in the SV and functional SV indices (P=0.045). None of the SBPV indices were significantly associated with the probability of hematoma expansion. Conclusions- Higher SBPV in the first 24 hours of admission was associated with unfavorable in-hospital outcome among ICH patients. Further prospective studies are warranted to understand any cause-effect relationship and whether controlling for SBPV may improve the ICH outcome.

Post-stroke infections and preventive antibiotics in stroke: Update of clinical evidence

This review provides an update of evidence on post-stroke infections and the use of preventive antibiotics in stroke. Infection is a common complication after stroke, affecting between 15% and 30% of the patients. The predictors for post-stroke infection can be divided into three categories: clinical factors, anatomical (stroke related) factors and immunological factors. The relation between the occurrence of a post-stroke infection and functional outcome remained subject of debate, but it seems likely that the occurrence of these infections has a causal relation with poor functional outcome and mortality. In the first meta-analysis on preventive antibiotic therapy, almost a decade ago, its beneficial effect on post-stroke infection rate was clear; however, the effect on functional outcome remained uncertain because included studies were small and heterogeneous. Afterwards, three large phase-3 RCTs were published and a Cochrane meta-analysis was performed. It has now become clear that, despite the finding that overall infections are reduced, preventive antibiotic therapy in the acute phase of stroke does neither improve functional outcome, nor decrease mortality rates. This does not yet mean that further research on preventive antibiotics in stroke is useless: the pathophysiology and etiology of post-stroke infections are unclear and the use of preventive antibiotics in specific subgroups of stroke patients could still be very effective. This is currently being studied. Besides, preventive antibiotic therapy might be cost-effective by increasing quality-adjusted life years. Thirdly, research for the upcoming years might put more emphasis on the effect of stroke on immunological alterations.

Risk factors for the development of chest infections in acute stroke: a systematic review

BACKGROUND

Chest infections occur in approximately one-third of patients following acute stroke, and are associated with poor outcomes. Limitations in previous reviews restricted the accuracy of results.

OBJECTIVES

To perform a systematic review to reliably identify modifiable risk factors for chest infections following acute stroke.

METHODS

Ovid Medline, CINAHL, Cochrane, EMBASE and AMED were searched from 1946 to April 2017 for observational studies where risk factors for chest infections in patients hospitalized with acute stroke were reported. Key words used to identify included chest infection or pneumonia. Included studies were evaluated based on methodological criteria and scientific quality. Results were collated and separate meta-analyses were performed for risk factors examined in three or more studies where quality and homogeneity criteria were met.

RESULTS

3172 studies were identified, 15 were eligible for inclusion. Data collection methods included primary data collection, medical record audit and registry data. Chest infections were diagnosed 2-30 days following acute stroke in ten studies. Of the 39 risk factors identified, four were included in the meta-analysis. These were mechanical ventilation: 4 studies, OR: 3.83, 95%CI: 3.21, 4.57; diabetes: 4 studies, OR: 1.06, 95%CI: 1.04, 1.08; pre-existing respiratory conditions: 3 studies, OR: 1.48, 95%CI 1.21, 1.81 and atrial fibrillation: 3 studies, OR: 1.21, 95%CI: 1.17, 1.24. Common risk factors not eligible for meta-analysis were dysphagia and cardiac comorbidities.

CONCLUSION

Evidence has been comprehensively synthesized to provide reliable estimates of the association between important risk factors and chest infection. Monitoring patients meeting these criteria may promote early identification and treatment to improve long-term outcomes.

Healthcare-associated infections in the neurological intensive care unit: Results of a 6-year surveillance study at a major tertiary care center

BACKGROUND

Healthcare-associated infections (HAIs) occur frequently in neurological intensive care units (neuro-ICUs); however, data differentiating associations with various diagnostic categories and resulting burdens are limited. This prospective cohort study reported incidence rates, pathogen distribution, and patient-related outcomes of HAIs in a neuro-ICU population from April 2010 to March 2016.

METHODS

Laboratory results and specific clinical indicators were used to categorize infections as per National Healthcare Safety Network nosocomial infection surveillance definitions. Patient outcomes studied included length of stay and mortality.

RESULTS

There were 6,033 neuro-ICU admissions resulting in 20,800 neuro-ICU days over the 6-year study period. A total of 227 HAIs were identified for a rate of 10.9/1,000 ICU days. Device-associated infections accounted for 80.6% of HAIs, with incidence rates (per 1,000 device days) being 18.4 for ventilator-associated pneumonia; 4.9 for catheter-associated urinary tract infections (CAUTIs); 4.0 for ventriculostomy-associated infections; and 0.6 for central line-associated blood stream infections (CLABSIs). Of the various diagnostic categories, subdural hematoma and intracerebral/intraventricular hemorrhage were associated with the highest pooled HAIs, with incidence rates of 21.3 and 21.1 per 1,000 neuro-ICU days, respectively. Prolonged neuro-ICU length of stay was strongly associated with all HAIs.

CONCLUSIONS

This large-scale surveillance study provides estimates of the risk of common HAIs in neurocritical care patients and their effect on hospitalization. Preventive strategies kept rates of infection very low, in particular CAUTI, CLABSI, and Clostridium difficile infections, and inhibited the emergence of resistant organisms.

Health Care-Associated Infections after Subarachnoid Hemorrhage

OBJECTIVE

Health care-associated infections (HAIs) after subarachnoid hemorrhage (SAH) are prevalent; however, data describing epidemiology of infection are limited. This study reports incidence rates, risk factors, and the resulting SAH patient-related outcomes.

METHODS

We studied the incidence of HAIs acquired in the intensive care unit (ICU) over a 6-year period. We used Bayesian Model Averaging to identify risk factors associated with an increased risk of HAIs, particularly urinary tract infections (UTI), pneumonia, and ventriculostomy-associated infections (VAI). We also examined the impact of HAIs on risk of vasospasm, ICU and hospital length of stay, and discharge disposition and adjusted for other risk factors.

RESULTS

Of 419 patients with SAH, 66 (15.8%) developed 79 HAI episodes. Mean HAI incidence rates (per 1000 ICU-days) were UTI, 7.1; pneumonia, 4.3; and VAI, 2.4. The admission characteristic associated with increased risk of overall HAI, UTI, and VAI was diabetes mellitus. Hunt and Hess grades III-V were associated with increased risk of overall HAI and VAI. Male gender, intraventricular hemorrhage, and blood glucose level (>10) were associated with increased risk of pneumonia, whereas the incidence was lower in the presence of steroids. HAI was associated with increased length of stay of 10 ICU-days and 22 hospital-days, but not vasospasm or poor discharge disposition.

CONCLUSIONS

HAIs are serious complications after SAH associated with prolonged ICU and hospital length of stay. Additional rigorous infection control measures aimed at patients with identifiable risk factors should trigger prevention, and early detection of nosocomial infections is warranted to further reduce the prevalence of HAIs.

Low incidence of multidrug-resistant bacteria and nosocomial infection due to a preventive multimodal nosocomial infection control: a 10-year single centre prospective cohort study in neurocritical care

Background

Nosocomial infection (NI) control is an important issue in neurocritical care due to secondary brain damage and the increased morbidity and mortality of primary acute neurocritical care patients. The primary aim of this study was to determine incidence of nosocomial infections and multidrug-resistant bacteria and seek predictors of nosocomial infections in a preventive multimodal nosocomial infection protocol in the neurointensive care unit (NICU). The secondary aim focused on their impact on stay, mortality and cost in the NICU.

Methods

A10-year, single-centre prospective observational cohort study was conducted on 3464 acute brain disease patients. There were 198 (5.7%) patients with nosocomial infection (wound 2.1%, respiratory 1.8%, urinary 1.0%, bloodstream 0.7% and other 0.1%); 67 (1.9%) with Extended spectrum beta-lactamase (ESBL); 52 (1.5%) with Methicillin-resistant Staphylococcus aureus (MRSA), nobody with Vancomycin-resistant enterococcus (VRE). The protocol included hygienic, epidemiological status and antibiotic policy. Univariate and multivarite logistic regression analysis was used for identifying predictors of nosocomial infection.

Results

From 198 NI patients, 153 had onset of NI during their NICU stay (4.4%; wound 1.0%, respiratory 1.7%, urinary 0.9%, bloodstream 0.6%, other 0.1%); ESBL in 31 (0.9%) patients, MRSA in 30 (0.9%) patients. Antibiotics in prophylaxis was given to 63.0% patients (59.2 % for operations), in therapy to 9.7% patients. Predictors of NI in multivariate logistic regression analysis were airways (OR 2.69, 95% CI 1.81-3.99, p<0.001), urine catheters (OR 2.77, 95% CI 1.00-7.70, p=0.050), NICU stay (OR 1.14, 95% CI 1.12-1.16, p<0.001), transfusions (OR 1.79, 95% CI 1.07-2.97, p=0.025) antibiotic prophylaxis (OR 0.50, 95% CI 0.34-0.74, p<0.001), wound complications (OR 2.30, 95% CI 1.33-3.97, p=0.003). NI patients had longer stay (p<0.001), higher mortality (p<0.001) and higher TISS sums (p<0.001) in the NICU.

Conclusions

The presented preventive multimodal nosocomial infection control management was efficient; it gave low rates of nosocomial infections (4.2%) and multidrug-resistant bacteria (ESBL 0.9%, MRSA 0.9% and no VRE). Strong predictors for onset of nosocomial infection were accesses such as airways and urine catheters, NICU stay, antibiotic prophylaxis, wound complications and transfusion. This study confirmed nosocomial infection is associated with worse outcome, higher cost and longer NICU stay.

Untreated hypertension as predictor of in-hospital mortality in intracerebral hemorrhage: A multi-center study

PURPOSE

Hypertension is a significant risk factor for intracerebral hemorrhage (ICH). The importance of managing blood pressure to reduce the risk of ICH has been recognized. However, few studies have focused on ICH outcomes due to untreated hypertension.

MATERIALS AND METHODS

We conducted a 5-year, retrospective, multicenter study of 490 consecutive ICH patients with histories of untreated-hypertension (n=56), treated-hypertension (n=314), and normotension (n=120). Demographics, symptom onset, vital signs, laboratory tests, and CT imaging were documented alongside in-hospital treatments, complications, and length of stay.

RESULTS

Untreated-hypertension subjects were found to be significantly younger than treated-hypertension. They were found to have lower rates of anticoagulant use (p<0.01), antiplatelet use (p<0.01), and hyperlipidemia (p<0.01) than subjects with treated-hypertension. In a multivariate model, untreated-hypertension, age ≥65years, ≥3 outpatient antihypertensive medications, and hematoma volumes ≥30ml were all associated with significantly increased in-hospital mortality. In contrast, mortality was lower in patients receiving ≥3 antihypertensive medications while in-hospital.

CONCLUSIONS

Subjects with untreated-hypertension were younger and had fewer comorbidities when compared with treated-hypertension and were similar when compared to normotensive individuals. Once demographic and in-hospital factors were accounted for, untreated-hypertension subjects demonstrated significantly increased in-hospital mortality following ICH when compared with normotensive individuals.

Pharmacokinetic/Pharmacodynamic Analysis of Meropenem for the Treatment of Nosocomial Pneumonia in Intracerebral Hemorrhage Patients by Monte Carlo Simulation

BACKGROUND

Nosocomial pneumonia (NP) is a frequent complication among patients with intracerebral hemorrhage (ICH). However, there are currently no pharmacokinetic (PK) and pharmacodynamic (PD) data to guide meropenem dosing in these patients.

OBJECTIVE

To investigate the PK/PD properties of meropenem in these patients and whether the usual dosing regimens of meropenem (2-hour infusion, 1 g, every 8 hours) was suitable.

METHODS

A total of 11 patients with a diagnosis of ICH complicated with NP were selected in the emergency internal medicine and treated with a 1-g/2-hours extended infusion model. The plasma concentrations of meropenem were determined by high-performance liquid chromatography. PK parameters were estimated by plasma concentration versus time profile using WinNonlin software. The probability of target attainments (PTAs) of meropenem at different minimum inhibitory concentrations (MICs) based on percentage time that concentrations were above the minimum inhibitory concentration (%T>MIC) value were performed by Monte Carlo simulation.

RESULTS

The volume of distribution and total body clearance of meropenem were 55.55 L/kg and 22.89 L/h, respectively. Using 40%T>MIC, PTA was >90% at MICs ≤4 µg/mL. Using 80% or 100%T>MIC, PTA was >90% only at MICs ≤1 µg/mL.

CONCLUSIONS

The PK/PD profile of dosing regimens tested will assist in selecting the appropriate meropenem regimens for these patients. At a target of 40%T>MIC, the usual dosing regimens can provide good coverage for pathogens with MICs of ≤4 µg/mL. However, when a higher target (80% or 100%) is desired for difficult-to-treat infections, larger doses, prolonged infusions, shorter intervals, and/or combination therapy may be required.

Risk factors for lung infection in stroke patients: a meta-analysis of observational studies

BACKGROUND

The aims of this meta-analysis were to evaluate the risk factors associated with lung infections in stroke patients and to provide evidence for prevention decisions.

METHODS

We searched the Embase, PubMed, EBSCO and Web of Science databases to collect studies from January 2000 to July 2015.

RESULTS

The meta-analysis identified 23 risk factors for lung infections in stroke patients, and the top 5, ranked by order according to odds ratio values (95% confidence interval), were as follows: multiple vertebrobasilar stroke, 22.99 (4.04, 130.83); National Institutes of Health Stroke Scale score >15 points, 14.63 (8.54, 25.08); mechanical ventilation, 10.20 (7.15, 14.57); nasogastric tube use, 9.87 (6.21, 15.70); and dysphagia, 7.50 (2.60, 21.65).

CONCLUSION

Preventive measures should be taken against these risk factors to reduce the incidence of lung infection.