Prevalence and predictive factors of urinary tract infection among patients with stroke: A meta-analysis

A novel score for early prediction of urinary tract infection risk in patients with acute ischemic stroke: a nomogram-based retrospective cohort study

This study aimed to construct and externally validate a user-friendly nomogram-based scoring model for predicting the risk of urinary tract infections (UTIs) in patients with acute ischemic stroke (AIS). A retrospective real-world cohort study was conducted on 1748 consecutive hospitalized patients with AIS. Out of these patients, a total of 1132 participants were ultimately included in the final analysis, with 817 used for model construction and 315 utilized for external validation. Multivariate regression analysis was applied to develop the model. The discriminative capacity, calibration ability, and clinical effectiveness of the model were evaluated. The overall incidence of UTIs was 8.13% (92/1132), with Escherichia coli being the most prevalent causative pathogen in patients with AIS. After multivariable analysis, advanced age, female gender, National Institute of Health Stroke Scale (NIHSS) score ≥ 5, and use of urinary catheters were identified as independent risk factors for UTIs. A nomogram-based SUNA model was constructed using these four factors (Area under the receiver operating characteristic curve (AUC) = 0.810), which showed good discrimination (AUC = 0.788), calibration, and clinical utility in the external validation cohort. Based on four simple and readily available factors, we derived and externally validated a novel and user-friendly nomogram-based scoring model (SUNA score) to predict the risk of UTIs in patients with AIS. The model has a good predictive value and provides valuable information for timely intervention in patients with AIS to reduce the occurrence of UTIs.

Prediction of upcoming urinary tract infection after intracerebral hemorrhage: a machine learning approach based on statistics collected at multiple time points

Purpose

Accurate prediction of urinary tract infection (UTI) following intracerebral hemorrhage (ICH) can significantly facilitate both timely medical interventions and therapeutic decisions in neurocritical care. Our study aimed to propose a machine learning method to predict an upcoming UTI by using multi-time-point statistics.

Methods

A total of 110 patients were identified from a neuro-intensive care unit in this research. Laboratory test results at two time points were chosen: Lab 1 collected at the time of admission and Lab 2 collected at the time of 48 h after admission. Univariate analysis was performed to investigate if there were statistical differences between the UTI group and the non-UTI group. Machine learning models were built with various combinations of selected features and evaluated with accuracy (ACC), sensitivity, specificity, and area under the curve (AUC) values.

Results

Corticosteroid usage (p < 0.001) and daily urinary volume (p < 0.001) were statistically significant risk factors for UTI. Moreover, there were statistical differences in laboratory test results between the UTI group and the non-UTI group at the two time points, as suggested by the univariate analysis. Among the machine learning models, the one incorporating clinical information and the rate of change in laboratory parameters outperformed the others. This model achieved ACC = 0.773, sensitivity = 0.785, specificity = 0.762, and AUC = 0.868 during training and 0.682, 0.685, 0.673, and 0.751 in the model test, respectively.

Conclusion

The combination of clinical information and multi-time-point laboratory data can effectively predict upcoming UTIs after ICH in neurocritical care.

Derivation and validation of a screening tool for stroke-associated sepsis

BACKGROUND

Post-stroke infections may cause sepsis, which is associated with poor clinical outcome. Sepsis is defined by life-threatening organ dysfunction that can be identified using the Sequential Organ Failure Assessment (SOFA) score. The applicability of the SOFA score for patients not treated on an intensive care unit (ICU) is limited. The aim of this study was to develop and validate an easier-to-use modification of the SOFA score for stroke patients.

METHODS

Using a registry-based cohort of 212 patients with large vessel occlusion stroke and infection, potential predictors of a poor outcome indicating sepsis were assessed by logistic regression. The derived score was validated on a separate cohort of 391 patients with ischemic stroke and infection admitted to our hospital over a period of 1.5 years.

RESULTS

The derived Stroke-SOFA (S-SOFA) score included the following predictors: National Institutes of Health stroke scale ≥ 14, peripheral oxygen saturation < 90%, mean arterial pressure < 70 mmHg, thrombocyte count < 150 10⁹/l and creatinine ≥ 1.2 mg/dl. The area under the receiver operating curve for the prediction of a poor outcome indicating sepsis was 0.713 [95% confidence interval: 0.665-0.762] for the S-SOFA score, which was comparable to the standard SOFA score (0.750 [0.703-0.798]), but the prespecified criteria for non-inferiority were not met (p = 0.115). However, the S-SOFA score was non-inferior compared to the SOFA score in non-ICU patients (p = 0.013).

CONCLUSIONS

The derived S-SOFA score may be useful to identify non-ICU patients with stroke-associated sepsis who have a high risk of a poor outcome.

Determinants of urinary tract infection in hospitalized patients with acute ischemic stroke

BACKGROUND

Stroke is a major cause of morbidity and mortality worldwide. Urinary tract infection (UTI) is a common post-acute ischemic stroke (AIS) complication. We assessed the incidence, determinant factors, infection characteristics, post-stroke complications, and outcomes of hospitalized AIS patients with UTI.

METHODS

This retrospective cohort study included AIS patients admitted within 7 days of stroke onset. The patients were divided into the UTI group and the non-UTI (control) group. Clinical data were collected and compared between the groups.

RESULTS

There were 342 AIS patients (31 with UTIs and 311 controls). The multivariate analysis showed that an initial National Institutes of Health Stroke Scale (NIHSS) score of ≥ 15 (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.33-18.72) and Foley catheter retention (OR 14.10, 95% CI 3.25-61.28) were risk factors for UTI, whereas smoking (OR 0.08, 95% CI 0.01-0.50), an initial systolic blood pressure (SBP) of > 120 mmHg (OR 0.06, 95% CI 0.01-0.31), and statin use (OR 0.02, 95% CI 0.0006-0.42) were protective factors. Twenty cases (64.5%) were community-acquired and 11 cases (35.3%) were hospital-acquired. Ten patients (32.3%) had catheter-associated UTIs. The most common pathogen was Escherichia coli (13 patients, 41.9%). Post-stroke complications were significantly more common in the UTI group, including pneumonia, respiratory failure, sepsis, brain edema, seizure, symptomatic hemorrhagic transformation, congestive heart failure, atrial fibrillation with a rapid ventricular response, acute kidney injury, and hyponatremia. The median length of stay (LOS) in the UTI group was 12 days versus 3 days in the control group (p < 0.001). The median 3-month modified Rankin Scale score was higher (5 in UTI and 2 in control; p < 0.001) and the median 3-month Barthel Index was lower (0 in UTI and 100 in control; p < 0.001) in the UTI group than in the control group.

CONCLUSIONS

The risk factors for post-AIS UTI included severe stroke (NIHSS score ≥ 15) and urethral catheter indwelling. An initial SBP of > 120 mmHg and statin use were protective factors. The UTI group had significantly worse post-stroke complications, a longer LOS, and worse 3-month outcomes. Smoking was protective, which requires further investigation.

Urinary tract infection in patients with lower urinary tract dysfunction

Lower urinary tract dysfunction (LUTD) is becoming more common in aging societies worldwide. In patients with LUTD, the risk of urinary tract infection (UTI) rises due to several distinct mechanisms, including easy bacterial access to the urinary tract, impaired bacterial washout, and an impaired innate defense system. The pathophysiology of LUTD varies depending on whether it is neurogenic or non-neurogenic, as well as by gender; therefore, the etiology and characteristics of UTI differ according to the type of LUTD. Patients with neurogenic LUTD, especially those with spinal cord injury, have a high risk of febrile UTI, and strict bladder management is required to prevent UTI. Clean intermittent catheterization with or without appropriate pharmacological therapy is also strongly recommended for patients with neurogenic LUTD at risk of febrile UTI, unable to void, or with high post-void residual volume. In contrast, both male and female patients with non-neurogenic LUTD have a lower risk of symptomatic UTI. There is insufficient evidence for non-neurogenic LUTD regarding the association between symptomatic UTI but not asymptomatic bacteriuria and LUTD severity, including the presence of post-void residual volume, or whether therapeutic intervention for LUTS reduces the incidence of UTI, particularly in male patients. In this narrative review, we aimed to highlight the pathogenesis, epidemiology, and management of UTI in patients with LUTD.

Dysphagia-related acute stroke complications: A retrospective observational cohort study

OBJECTIVES

Post-stroke dysphagia is associated with aspiration pneumonia, but strategies intended to mitigate this complication, such as oral intake modifications, may unintentionally lead to dehydration-related complications such as urinary tract infections (UTIs) and constipation. This study aimed to determine the rates of aspiration pneumonia, dehydration, UTI and constipation in a large cohort of acute stroke patients and the independent predictors of each complication.

MATERIALS AND METHODS

Data were extracted retrospectively for 31,953 acute stroke patients admitted to six hospitals in Adelaide, South Australia over a 20-year period. Tests of difference compared rates of complications between patients with and without dysphagia. Multiple logistic regression modelling explored variables that significantly predicted each complication.

RESULTS

In this consecutive cohort of acute stroke patients, with a mean (SD) age of 73.8 (13.8) years and 70.2% presenting with ischaemic stroke, rates of complications were: aspiration pneumonia (6.5%); dehydration (6.7%); UTI (10.1%); and constipation (4.4%). Each complication was significantly more prevalent for patients with dysphagia compared to those without. Controlling for demographic and other clinical variables, the presence of dysphagia independently predicted aspiration pneumonia (OR=2.61, 95% CI 2.21-3.07; p<.001), dehydration (OR=2.05, 95% CI 1.76-2.38; p<.001), UTI (OR=1.34, 95% CI 1.16-1.56; p<.001), and constipation (OR=1.30, 95% CI 1.07-1.59; p=.009). Additional predictive factors were increased age and prolonged hospitalisation.

CONCLUSIONS

Aspiration pneumonia, dehydration, UTI, and constipation are common acute sequelae of stroke and independently associated with dysphagia. Future dysphagia intervention initiatives may utilise these reported complication rates to evaluate their impact on all four adverse health complications.

The efficacy and safety of prophylactic antibiotics for post-acute stroke infection: A systematic review and meta-analysis

AIMS

Infections are common complications after stroke and associated with unfavourable outcomes. We aimed to evaluate the efficacy and safety of prophylactic antibiotics for post-acute stroke infection.

METHODS

We searched PubMed, Embase, the Cochrane Library, SinoMed, China National Knowledge Infrastructure, WanFang Data, China Science and Technology Journal Database, and clinical trial register platforms from inception to 15 February 2022. We included randomized clinical trials that evaluated the efficacy and safety of prophylactic antibiotics. Primary outcomes were mortality rate and incidence of pneumonia. The pooled risk ratio (RR) and mean differences with 95% confidence interval (CI) were calculated using the random or fixed-effect model depending on heterogeneity. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

Twelve studies (4809 participants) were included. There was no significant difference in the mortality rate (12 trials, n = 4740, RR 1.03 [95% Cl: 0.91-1.16], high-quality evidence), incidence of pneumonia (7 trials, n = 4352, RR 0.94 [95% CI: 0.79-1.11], high-quality evidence) and the incidence of adverse events between the prophylactic antibiotics and control groups. Prophylactic antibiotics significantly reduced the incidence of infections (8 trials, n = 4517, RR 0.72 [95% CI: 0.58-0.89], moderate-quality evidence) and urinary tract infections (7 trials, n = 4352, RR 0.39 [95% CI: 0.3-0.49], moderate-quality evidence). None of the subgroup analyses showed a significant difference in mortality or the incidence of pneumonia.

CONCLUSION

For acute stroke patients, prophylactic antibiotics were significantly associated with fewer incidences of any infections and urinary tract infections without significant differences in mortality rate and pneumonia.

The Influence of Periodontal Diseases and the Stimulation of Saliva Secretion on the Course of the Acute Phase of Ischemic Stroke

Background and purpose: The course of an ischemic stroke depends on many factors. The influence of periodontal diseases and the stimulation of salivation on the course and severity of stroke remains unresolved. Therefore, the aim of the study was to analyze the severity of ischemic stroke depending on the occurrence of periodontal diseases and saliva stimulation. Methods: The severity of the neurological condition was assessed using the NIHSS scale on days one, three and seven of stroke. The incidence of periodontal diseases was classified using the Hall’s scale in the first day of stroke. On days one and seven of stroke, the concentration of IL-1β, MMP-8, OPG and RANKL in the patients’ saliva was assessed using the Elisa technique. At the same time, the level of CRP and the number of leukocytes in the peripheral blood were tested on days one, three and seven of the stroke, and the incidence of upper respiratory and urinary tract infections was assessed. Results:100 consecutive patients with their first ever ischemic stroke were enrolled in the study. 56 randomly selected patients were subjected to the stimulation of salivation, the remaining patients were not stimulated. In the study of the severity of the neurological condition using the NIHS scale on days three and seven of stroke, the degree of deficit in patients without periodontal disease significantly improved compared to patients with periodontal disease, respectively (p < 0.01 and p = 0.01). Patients from the stimulated group had more severe neurological deficit at baseline (p = 0.04). On days three and seven of neurological follow-up, the condition of patients from both groups improved with a further distinct advantage of the unstimulated group over the stimulated group, respectively (p = 0.03 and p < 0.001). In patients from both groups, a statistically significant decrease in CRP and lymphocyte levels was observed on day seven in relation to day one. Conclusions: The occurrence of periodontal disease in a patient with stroke affects the severity of stroke. Stimulation of the mouth and salivary glands in these patients may have a positive effect on the course of stroke, taking into account the dynamics of neurological symptoms.

Sepsis in Patients With Large Vessel Occlusion Stroke–Clinical Characteristics and Outcome

Background

Infections are an important complication after stroke and negatively affect clinical outcome. While pneumonia and urinary tract infections are well recognized after stroke, the incidence and consequences of sepsis remain unclear. The aim of this study was to evaluate the frequency and characteristics of sepsis in patients undergoing endovascular therapy for large vessel occlusion stroke, and its association with clinical outcome.

Methods

We analyzed a cohort of patients who underwent endovascular therapy at a single center between 2016 and 2020. The diagnosis and timing of infections and Sequential Organ Failure Assessment scores were evaluated retrospectively to identify patients with sepsis. Patients with sepsis were compared to controls regarding clinical characteristics and outcome.

Results

Fifty-four of 406 patients (13.3%) were found to have sepsis. The median onset of sepsis was 2 days after admission. The majority of cases (85.2%) was caused by pneumonia. At 3 months, 72.5% of patients with sepsis were bedridden or dead compared to 25.7 and 42.7% of controls and patients with an infection without sepsis, respectively. The adjusted odds ratio (95% confidence interval) for a poor outcome was 5.4 (1.6–17.6) for patients with sepsis vs. controls, and 2.0 (0.8–5.2) for patients with sepsis vs. patients with an infection without sepsis.

Conclusions

Sepsis is a frequent complication after large vessel occlusion stroke, and may be associated with a poor clinical outcome. More studies are needed to determine specific risk factors and measures to early recognize and reduce the possibly negative impact of sepsis on outcome after stroke.

Incidence, risk factors and microbiological aetiology of urinary tract infections in admitted stroke patients at a teaching hospital in Zimbabwe: A prospective cohort study

Background and purpose

The occurrence of urinary tract infections (UTIs) after stroke is a well recognised complication. The aim of this study was to determine the incidence of UTIs in stroke patients admitted at a teaching hospital in Zimbabwe.

Methods

A prospective cohort study was conducted in stroke patients admitted within 7 days from onset of stroke. Patients were followed up throughout the admission period and those with symptomatic UTI were identified. Urine samples for analysis were collected and causative bacterial organisms were identified with their antibiotic susceptibility patterns analysed.

Results

A total of 145 stroke patients were followed up during their in-patient care. 28 patients (19.3%) developed a urinary tract infection, 45 patients (31%) had asymptomatic bacteriuria and 72 patients (49.7%) had no bacteriuria. The median time from admission to UTI occurrence post stroke was 5 (IQR 4–7) days. Severe stroke (NIHSS score 16–42) was an independent risk factor for UTI development with an odds ratio (OR) 5.15 (1.68–15.75) p<0.001.The commonest bacterial causative organisms cultured were Escherichia coli (27.6%) ; Klebsiella species (21.1%) and Enterococcus faecalis (19.7%). Twenty nine percent of the cultured Gram negative bacteria were extended-spectrum beta-lactamase (ESBL) producers.

Conclusions

UTIs are common in admitted stroke patients and a significant percentage of causative organisms are multi-drug resistant. UTI occurrence is more common in patients with severe stroke and is associated with increased hospital stay. These observations highlight the need for robust infection prevention and control strategies to curb this common post-stroke complication.

Policy analysis on power standing systems

Power wheelchairs provide people with mobility disabilities opportunities for independence in mobility and repositioning themselves. However, current power wheelchair power options covered by Medicare limit the person to a horizontal plane. In the home, access to the vertical plane is also required for mobility related activities of daily living. Power standing systems on power wheelchairs are one option for providing access to the vertical environment, although currently these systems are not covered by Medicare. Power standing systems also aid in medical management and in preventing common comorbidities associated with chronic neurological and congenital healthcare conditions. Therefore, a legal group led an interdisciplinary effort to change Medicare policy on power standing systems. A policy analysis using Bardach’s Eightfold policy framework was conducted to analyze a clinical groups’ action within this interdisciplinary team. The clinical team considered three viable options to address the problem and evaluated these options against five criteria. Ultimately, a national coverage determination reconsideration would provide a needed opportunity for the coverage of power standing systems. Suggested coverage criteria for power standing systems, based on existing literature and expert clinical experience, are proposed.

Comparison of stroke cases with other neurological diseases on the basis of haemogram parameters

AIMS

This study aimed to examine the haemogram parameters, including the neutrophil/lymphocyte ratio (NLR), which is fast, easy and practical to determine, in stroke patients who present with more physiological stress and inflammation and compare them with patients presenting other neurological diseases.

METHODS

The demographic, laboratory and imaging features of all patients who were admitted to the neurology clinic within a three-year period and met the study criteria were retrospectively analysed. A haemogram from peripheral venous blood samples was taken at the time of admission, and its parameters was calculated.

RESULTS

A total of 3152 patients, 1604 of whom were women (50.9%), with a mean age of 66.1 ± 14 (18-100) years who were hospitalised in the neurology clinic from 1 January 2015 to 1 January 2018, comprised the study's sample. Mean age, mean leukocyte-neutrophil count and NLR were significantly higher in stroke patients than in those without stroke (P < .001, P < .001 and P < .001, respectively), but mean red blood cell, platelet and lymphocyte counts, and haemoglobin and haematocrit values were found to be significantly lower (P < .001, P < .001, P < .001, P < .001 and P < .001, respectively). When the haemogram parameters were compared according to stroke type, red blood cell, haemoglobin, haematocrit and NLR values in patients with haemorrhagic stroke (P = .019, P = .002, P = .002 and P = .001, respectively) and platelet and lymphocyte values in ischaemic stroke patients were found to be significantly higher (P = .002 and P < .001, respectively).

CONCLUSION

In this study, significant data obtained by comparing the haemogram parameters of those with stroke and other neurological diseases are presented. All neurological diseases, especially acute stroke and its types, should be examined in future prospective, randomised and controlled studies with all haemogram parameters, especially the NLR. However, it should be noted that haematological parameters are more useful for group studies rather than determining the diagnosis of an individual patient.

Ischemic stroke and infection: A brief update on mechanisms and potential therapies

Ischemic stroke triggers a multifaceted inflammatory response in the brain that contributes to secondary brain injury and infarct expansion. In parallel with brain inflammation, ischemic stroke also leads to post-stroke immunosuppression. Stroke-induced leukopenia then predisposes patients to opportunistic infections potentially leading to pneumonia or unrinary tract infections and a worsened stroke outcome. There is evidence that the hypothalamic-pituitaryadrenal axis plays an important role in the etiology of post-stroke immunosuppression, by which prolonged glucocorticoid signalling leads to changes in immune responses. While opportunistic microbes in hospitals have been thought to be the source of infection, recent studies have reported that gut flora may also be a cause of post-stroke infection as a consequence of compromised integrity of the gut barrier after stroke. While antimicrobial drugs would appear to be a rational form of treatment for bacterial infections in stroke patients, the rise in drug-resistant bacteria and possible adverse effects of disrupting beneficial gut flora represent major challenges with these drugs. Considering the prominent role of gut microbiota in modulating immune responses, protecting and restoring the post-stroke gut bacteriome may provide significant benefit in the context of post-stroke infection. With such broad aspects of post-stroke infection occurring together with an extensive inflammatory response in the brain, a carefully considered administration of therapies for ischemic stroke is warranted.

Usefulness of the Neutrophil-to-Lymphocyte Ratio as a Predictor of Pneumonia and Urinary Tract Infection Within the First Week After Acute Ischemic Stroke

Background: A high Neutrophil-to-Lymphocyte ratio (NLR) in patients with acute ischemic stroke (AIS) has been associated with post-stroke infections, but it's role as an early predictive biomarker for post-stroke pneumonia (PSP) and urinary tract infection (UTI) is not clear.

Aim: To investigate the usefulness of NLR obtained within 24 h after AIS for predicting PSP and UTI in the first week.

Methods: Clinical and laboratory data were retrieved from the University Hospital Brussels stroke database/electronic record system. Patients were divided into those who developed PSP or UTI within the first week after stroke onset and those who didn't. Receiver operating characteristics (ROC) curves and logistic regression analysis were used to identify independent predictors.

Results: Five hundred and fourteen patients were included, of which 15.4% (n = 79) developed PSP and 22% (n = 115) UTI. In univariate analysis, NLR was significantly higher in patients who developed PSP (4.1 vs. 2.8, p < 0.001) but not in those who developed UTI (3.3 vs. 2.9, p = 0.074). Multiple logistic regression analysis for PSP showed that NLR, male gender, dysphagia, and stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS), were independent predictors of PSP. For NLR alone, the area under the curve (AUC) in the ROC curve was 0.66 (95% CI = 0.59–0.73). When combining NLR ≥ 4.7 with age >75 years, male gender, NIHSS > 7, and dysphagia, the AUC increased to 0.84 (95% CI = 0.79–0.89).

Conclusion: The NLR within 24 h after AIS appears to have no predictive value for post-stroke UTI, and is only a weak predictor for identifying patients at high risk for PSP. Its predictive value for PSP appears to be much stronger when incorporated in a prediction model including age, gender, NIHSS score, and dysphagia.

The effect of a supportive home care program on caregiver burden with stroke patients in Iran: an experimental study

Background

Stroke can impose a heavy burden on caregivers. Caring for stroke patients at home is more challenging than in hospitals with facilities. The purpose of this study was to evaluate the effect of a supportive home care program on caregiver burden with stroke patients.

Methods

This was an experimental study. One hundred sixteen caregivers of stroke patients were recruited using convenience sampling from two university-affiliated hospitals in Tehran from June 2019 to February 2020. They were randomly allocated into two groups (supportive home care program and routine hospital education program) using a randomized block design. The supportive home care program included eight educational sessions delivered in the hospital before discharge, and with home visits after hospital discharge. Caregiver burden was measured using Caregiver Burden Inventory. The data were analyzed using independent samples t-test and Analysis of Covariance.

Results

Caregiver burden in the routine education group increased significantly after 2 weeks, from 52.27 ± 23.95 to 62.63 ± 22.68. The mean of caregiver burden scores in the supportive home care program decreased from 44.75 ± 17.21 to 40.46 ± 17.28. The difference between the scores of the two groups before the intervention was not significantly different (t = 1.941, df = 114, p = 0.055). There was a significant difference between the two groups regarding caregiver burden scores after the intervention period (η² = 0.305, P < 0.001).

Conclusions

Caregiver burden increased significantly after the discharge without proper interventions in the caregivers of stroke patients. Providing support for home care providers can help to decrease or prevent the intensification of caregiver burden.

Prevalence and Predictive Factors for Nosocomial Infection in the Military Hospitals: A Systematic Review and Meta-Analysis

Background:

To assess prevalence and predictive factors for Nosocomial Infection (NI) in the military hospitals.

Methods:

PubMed, Scopus, Cochrane and PreQuest databases were systematically searched for studies published between Jan 1991 and Oct 2017 that reported the prevalence of NI and predictive factors among military hospitals. We performed the meta-analysis using a random effects model. Subgroup analysis was done for heterogeneity and the Egger test to funnel plots was used to assess publication bias.

Results:

Twenty-eight studies with 250,374 patients were evaluated in meta-analysis. The overall pooled estimate of the prevalence of NI was 8% (95% 6.0–9.0). The pooled prevalence was 2% (95% CI: 2.0–3.0) when we did sensitivity analysis and excluding a study. The prevalence was highest in burn unit (32%) and ICU (15%). Reported risk factors for NI included gender (male vs female, OR: 1.45), age (Age≥65, OR: 2.4), diabetes mellitus (OR: 2.32), inappropriate use of antibiotics (OR: 2.35), received mechanical support (OR: 2.81), co-morbidities (OR: 2.97), admitted into the ICU (OR: 2.26), smoking (OR: 1.36) and BMI (OR: 1.09).

Conclusion:

The review revealed a difference of prevalence in military hospitals with other hospitals and shows a high prevalence of NI in burn units. Therefore careful disinfection and strict procedures of infection control are necessary in places that serve immunosuppressed individuals such as burn patient. Moreover, a vision for the improvement of reports and studies in military hospitals to report the rate of these infections are necessary.

Predictors of urinary tract infection in acute stroke patients: A cohort study

Patients with stroke have a high risk of infection which may be predicted by age, procalcitonin, interleukin-6, C-reactive protein, National Institute of Health stroke scale (NHSS) score, diabetes, etc. These prediction methods can reduce unfavourable outcome by preventing the occurrence of infection.We aim to identify early predictors for urinary tract infection in patients after stroke.In 186 collected acute stroke patients, we divided them into urinary tract infection group, other infection type groups, and non-infected group. Data were recorded at admission. Independent risk factors and infection prediction model were determined using Logistic regression analyses. Likelihood ratio test was used to detect the prediction effect of the model. Receiver operating characteristic curve and the corresponding area under the curve were used to measure the predictive accuracy of indicators for urinary tract infection.Of the 186 subjects, there were 35 cases of urinary tract infection. Elevated interleukin-6, higher NIHSS, and decreased hemoglobin may be used to predict urinary tract infection. And the predictive model for urinary tract infection (including sex, NIHSS, interleukin-6, and hemoglobin) have the best predictive effect.This study is the first to discover that decreased hemoglobin at admission may predict urinary tract infection. The prediction model shows the best accuracy.

Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study

BACKGROUND

While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions.

OBJECTIVES

The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China.

DESIGN

A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective.

SETTINGS

Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China.

PARTICIPANTS

A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017.

METHODS

To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months.

RESULTS

Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥-517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly.

CONCLUSIONS

Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally.

Catheter-Associated Urinary Tract Infection (CAUTI) in the NeuroICU: Identification of Risk Factors and Time-to-CAUTI Using a Case-Control Design

BACKGROUND/OBJECTIVE

Catheter-associated urinary tract infections (CAUTIs) account for 25% of all hospital-acquired infections. Neuro-critically ill patients are at 2-5 times greater risk of developing CAUTI because of increased use of indwelling urinary catheters due to neurogenic urinary retention. Despite the heightened risk of CAUTI occurrence for the neuro-critically ill, there is little data on specific characteristics of CAUTIs and risk factors among this population. The aim of this study was to identify characteristics and risk factors associated with CAUTI development in the neuro-critical patient population.

METHODS

In this retrospective single-center case-control study in a tertiary care dedicated 30-bed neuroICU, approximately 3 controls (exact ratio-3.2) were randomly selected for each CAUTI case between January 1st, 2016 and December 31st, 2018. Demographic, clinical and laboratory data were collected, including prospectively collected data pertaining to urinary and bowel function. Descriptive and multivariate logistic regression analysis was conducted to identify common patient characteristics, CAUTI risk factors and duration from catheterization to developing a CAUTI (Time-to-CAUTI).

RESULTS

Of 3045 admissions during the study period, 1045 (34.30%) had a urinary catheter at some point during their admission. Of those, 45 developed a CAUTI, yielding a CAUTI incidence rate of 1.50%, corresponding to 4.49 infections/1000 catheter days. On average, CAUTI patients were older as compared to controls (66.44 years of age vs 58.09 years; p < 0.0001). In addition to old age, other risk factors included female gender (75.60% female vs 24.20% males in case group, p < 0.0001), increased neuroICU length of stay (18.31 in cases vs. 8.05 days in controls, p = 0.0001) and stool incontinence (OR = 3.73, p = 0.0146). CAUTI patients more often carried a primary diagnosis of SAH, and comorbidities of hypertension (HTN), vasospasm and diabetes. Time-to-CAUTI was 6 days on average, with an earlier peak for patients requiring two or more catheter placements. Presence of stool incontinence was significantly associated with CAUTI occurrence.

CONCLUSION

Stool incontinence, older age, female sex, longer neuroICU LOS and presence of comorbidities such as HTN and diabetes were associated with CAUTI development in the neuro-critically ill population. Average Time-to-CAUTI after catheter placement was 6 days with earlier occurrence if more frequent catheterizations. Colonization of urinary catheters without infection might contribute to CAUTI diagnosis. Prospective research is needed to determine impact of prevention protocols incorporating these factors.

A risk prediction model of urinary tract infections for patients with neurogenic bladder

Objectives: To develop a nomogram to evaluate the risk of urinary tract infections (UTI) in patients with neurogenic bladder (NGB)Methods: A retrospective analysis was conducted on 337 patients with NGB admitted to three hospitals. Collected data included clinical symptoms, patients' general characteristics, laboratory examinations and imaging findings. Multivariate logistic regression analysis was conducted to develop the risk prediction nomogram of UTIs for NGB patients. C index was used for the internal and external validation of that model.Results: The occurrence of UTIs was 45.7% (154 of 337), 52.6% (102 of 194), and 36.4% (52 of 143) in the overall, training and validation data sets, respectively. The prediction nomogram was developed with 5 prognostic factors which included white blood cell (WBC) in blood, Leukocyte (LEU) in urine, Urinary pH, length of stay and urination mode. The nomogram presented good discrimination with a C-index value of 0.921 (95% confidence interval: 0.87396 - 0.96804) and good calibration. The C-index values of the interval validation and external validation were 0.8905541 and 0.817, respectively. The results of decision curve analysis (DCA) demonstrated that the model was clinically useful.Conclusions: The prediction nomogram we developed is a simple and accurate tool for early prediction of UTIs in patients with NGB. This tool can assess risk of UTIs early, allowing for timely initiation of appropriate preventive measures.

A Retrospective Study on Risk Factors for Urinary Tract Infection in Patients with Intracranial Cerebral Hemorrhage

Objective

This study aimed to explore the risk factors of urinary tract infection (UTI) in patients with intracranial cerebral hemorrhage (ICH).

Design

This is a retrospective study, and a total of 77 patients with ICH consecutively admitted to the First Affiliated Hospital of USTC (Anhui Provincial Hospital, Hefei, China) during the period of August 2015 to August 2017 were included. The patients were divided into an UTI group (24 cases) and a non-UTI group (53 cases); patients with UTI were diagnosed according to clinical manifestations, recent urinary routines, and urine culture results. The following information in these two groups was recorded: age, sex, course of disease, side of paralysis, location and type of cerebral hemorrhage, disturbance of consciousness or not, the Brunnstrom stage of paralysed lower limbs, number of basic diseases, whether there were complications (tracheotomy, retention catheterization, pulmonary infection, pressure sore, deep venous thrombosis, etc.), whether rehabilitation interventions were conducted, blood routine, biochemistry index, DIC complete set, urine routine, and urine culture data. Univariate analysis and multivariate logistic regression analysis were used to examine the risk factors of UTI in patients with ICH.

Results

Univariate analysis showed that age, side of paralysis, disturbance of consciousness, the Brunnstrom stage of lower limbs, tracheotomies, retention catheterization, pulmonary infection, leukocyte count, neutrophil proportion, sodium, uric acid, D-dimer, and fibrinogen may be related to UTI in patients with ICH (P < 0.05). Regression analysis showed that age (OR (95% CI) = 1.207 (1.022–1.424), P < 0.05). Regression analysis showed that age (OR (95% CI) = 1.207 (1.022–1.424), P < 0.05). Regression analysis showed that age (OR (95% CI) = 1.207 (1.022–1.424), P < 0.05). Regression analysis showed that age (OR (95% CI) = 1.207 (1.022–1.424),

Conclusions

Increased age and high D-dimer are independent risk factors for UTI in patients with ICH, while right-sided paralysis is a protective factor for UTI in patients with ICH.

Priority Nursing Interventions Caring for the Stroke Patient

Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient.

Prevalence, incidence, and risk factors of urinary tract infection among immobile inpatients in China: a prospective, multi-centre study

BACKGROUND

Immobile inpatients have a high risk of urinary tract infection (UTI). Additional epidemiological data regarding UTIs among immobile inpatients are needed.

AIM

To investigate the prevalence and incidence of, and risk factors for, UTIs among immobile patients in 25 hospitals throughout China.

METHODS

This was a national multi-centre cross-sectional investigation. We recruited six tertiary hospitals, 12 non-tertiary hospitals, and seven community hospitals. We obtained data regarding demographics, clinically related variables, and UTI-specific variables from immobile patients during their hospitalization. We performed univariate and multivariable analyses, and binary logistic regression analysis was used to identify risk factors.

FINDINGS

Among 23,985 immobile patients, 393 had a UTI. The prevalence and incidence of UTIs in hospitalized immobile patients was 1.64% (393/23 985) and 0.69 per 1000 patient-days, respectively. The infection rate of catheter-associated UTI was 2.25 per 1000 urinary catheter-days. We found that a greater number of bedridden days, longer length of hospital stay, being in a medical ward, the presence of an indwelling urethral catheter, prolonged duration of an indwelling catheter, use of glucocorticoids, female sex, diabetes mellitus, and older age were independent risk factors of UTI.

CONCLUSION

Immobile patients had similar risk factors for UTI as the general population, as well as some additional risk factors. Greater attention is needed in the management of UTIs among the population of immobile hospitalized patients.

The effects of a standardized nursing intervention model on immobile patients with stroke: a multicenter study in China

BACKGROUND

Immobility complications, including pressure injuries (PIs), deep vein thrombosis (DVT), pneumonia, and urinary tract infections (UTIs), affect the clinical outcomes of stroke patients. A standardized nursing intervention model (SNIM) was constructed and implemented to improve the quality of care and clinical outcomes among immobile patients with stroke.

AIMS

To assess the benefit of SNIM for immobility complication rates, including PIs, DVT, pneumonia, and UTIs, and mortalities in immobile patients with stroke.

METHODS

A before and after study design was used. Patients were divided into a pre- and post-SNIM training original cohort and matched for socioeconomic, demographic, and disease characteristics using propensity score. We fitted logistic regression models to examine the effect of SNIM, and whether the benefit differed between tertiary and non-tertiary hospitals.

RESULTS

In the original cohort, the rate of pneumonia, UTIs, and mortality was lower after SNIM training. Furthermore, in the matched cohort, the difference in PI rates was significant. Logistic regression analysis revealed that the probability of PIs, pneumonia, UTIs, and mortality were significantly reduced after SNIM training in the original cohort and this estimated value changed little in the matched cohort. Our results show that the decreased rates of pneumonia, UTIs, and mortality were mainly among non-tertiary hospitals.

CONCLUSIONS

A structured and systematic SNIM benefited immobile stroke patients' clinical outcomes, but mainly in non-tertiary hospitals in China. Standardized nursing training is needed in non-tertiary hospitals.

Hospital-Level Variations in Rates of Inpatient Urinary Tract Infections in Stroke

Background and purpose: Urinary tract infection (UTI) is one of the most common complications following stroke and has prognostic significance. UTI rates have been shown to vary between hospitals, but it is unclear whether this is due to case-mix differences or heterogeneities in care among hospitals.

Methods: A prospective multi-center cohort study of acute stroke patients admitted to eight National Health Service (NHS) acute hospital trusts within the Anglia Stroke & Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospital (as a fixed-effect) and inpatient UTI using a multivariable logistic regression model, adjusting for established patient-level risk factors. We graphically and descriptively analyzed heterogeneities in hospital-level characteristics.

Results: We included 2,241 stroke admissions in our analysis; 171 (7.6%) acquired UTI as an inpatient. UTI rates varied significantly between the eight hospitals, ranging from 3 to 11%. The hospital that had the lowest odds of UTI [odds ratio (OR) = 0.50 (95% confidence interval (CI) 0.22–.11)] in adjusted analysis, had the highest number of junior doctors and occupational therapists per five beds of all hospitals. The hospital with the highest adjusted UTI rate [OR=2.69 (1.56–4.64)] was tertiary, the largest and had the highest volume of stroke patients, lowest number of stroke unit beds per 100 admissions, and the highest number of hospital beds per CT scanner.

Conclusions: There is hospital-level variation in post-stroke UTI. Our results suggest the potential influence of service characteristics independently of patient-level factors which may be amenable to be addressed to improve the ultimate stroke outcome.

Antibiotic Class and Outcome in Post-stroke Infections: An Individual Participant Data Pooled Analysis of VISTA-Acute

Introduction: Antibiotics used to treat post-stroke infections have differing antimicrobial and anti-inflammatory effects. Our aim was to investigate whether antibiotic class was associated with outcome after post-stroke infection. Methods: We analyzed pooled individual participant data from the Virtual International Stroke Trials Archive (VISTA)-Acute. Patients with ischemic stroke and with an infection treated with systemic antibiotic therapy during the first 2 weeks after stroke onset were eligible. Antibiotics were grouped into eight classes, according to antimicrobial mechanism and prevalence. The primary analysis investigated whether antibiotic class for any infection, or for pneumonia, was independently associated with a shift in 90 day modified Rankin Scale (mRS) using ordinal logistic regression. Results: 2,708 patients were eligible (median age [IQR] = 74 [65 to 80] y; 51% female; median [IQR] NIHSS score = 15 [11 to 19]). Pneumonia occurred in 35%. Treatment with macrolides (5% of any infections; 9% of pneumonias) was independently associated with more favorable mRS distribution for any infection [OR (95% CI) = 0.59 (0.42 to 0.83), p = 0.004] and for pneumonia [OR (95% CI) = 0.46 (0.29 to 0.73), p = 0.001]. Unfavorable mRS distribution was independently associated with treatment of any infection either with carbapenems, cephalosporins or monobactams [OR (95% CI) = 1.62 (1.33 to 1.97), p < 0.001], penicillin plus β-lactamase inhibitors [OR (95% CI) = 1.26 (1.03 to 1.54), p = 0.025] or with aminoglycosides [OR (95% CI) = 1.73 (1.22 to 2.46), p = 0.002]. Conclusion: This retrospective study has several limitations including effect modification and confounding by indication. Macrolides may have favorable immune-modulatory effects in stroke-associated infections. Prospective evaluation of the impact of antibiotic class on treatment of post-stroke infections is warranted.