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Kim NY, Jung Y, Hong SB, Ahn JH, Choi SI, Kim YW. Low Phase Angle and Skeletal Muscle Index Increase Hospital-Acquired Infections During Stroke Rehabilitation. J Am Med Dir Assoc 2024; 25:683-689.e1. [PMID: 38163642 DOI: 10.1016/j.jamda.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Sarcopenia is common in patients with stroke and may increase the risk of medical complications such as infection. However, assessing sarcopenia in stroke patients with consciousness disturbance, aphasia or severe paralysis is challenging. This study aimed to investigate whether a combined assessment of phase angle (PhA) and skeletal muscle index (SMI), estimated using bioelectrical impedance analysis, was associated with 2 common nosocomial infections, hospital-acquired pneumonia (HAP) and urinary tract infection (UTI), during inpatient stroke rehabilitation. DESIGN Single-center retrospective observational study. SETTINGS AND PARTICIPANTS A total of 1068 patients with stroke admitted to a rehabilitation hospital between January 2016 and September 2019 were analyzed. METHODS The study variables included demographic characteristics, comorbidities, stroke severity, blood chemistry and urine analysis, SMI, and PhA obtained using bioelectrical impedance analysis. Patients were classified as normal, low PhA only, low SMI only, and low PhA + SMI. Multivariate Cox proportional analysis was used to determine the variables associated with HAP and UTI. RESULTS A combination of low PhA + SMI was observed in 429 (40.2%) patients. Over a median follow-up duration of 46 days, HAP occurred in 187 patients (17.5%) and UTI occurred in 155 patients (14.5%). The low PhA + SMI group showed a significantly higher incidence of HAP and UTI than the normal group (32.6% vs 4.6%, P < .001, for HAP; 20.7% vs 6.2%, P < .001, for UTI). In multivariate Cox analyses, low PhA and SMI were associated with significantly higher rates of HAP [hazard ratio (HR) 3.36, 95% CI 1.796-6.304, P < .001] and UTI (HR 1.71, 95% CI 1.002-2.947, P < .05) after adjusting for confounding variables. CONCLUSIONS AND IMPLICATIONS Combination of low PhA + SMI was independently associated with a higher risk of HAP and UTI in stroke patients who underwent inpatient rehabilitation. Measuring PhA and SMI using bioelectrical impedance analysis might be helpful in establishing care plans in these population.
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Affiliation(s)
- Na Young Kim
- Department of Rehabilitation Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea.
| | - Yusang Jung
- Department and Research Institute of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Been Hong
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Jeong Hyeon Ahn
- Department and Research Institute of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Ick Choi
- Department of Rehabilitation Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Yong Wook Kim
- Department and Research Institute of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Rabaneda-Lombarte N, Faura J, Ezcurra-Díaz G, Olivé-Gadea M, Álvarez-Larruy M, Vidal-de Francisco D, Domínguez-Mayoral A, Avellaneda C, Freijo MM, Zapata-Arriaza E, Serrano-Heras G, Alcahut-Rodríguez C, Fernández-Pérez I, Moniche F, Pérez-Sánchez S, Millán M, Rubiera M, Dorado L, Maisterra O, Montaner J, Bustamante A. Stroke-associated pneumonia according to mCDC criteria: impact on prognosis and antibiotic therapy. Front Neurol 2024; 15:1358628. [PMID: 38497035 PMCID: PMC10941756 DOI: 10.3389/fneur.2024.1358628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Objective The modified Centers for Disease Control and Prevention (mCDC) criteria have been proposed for diagnosing and managing stroke-associated pneumonia (SAP). The objective was to investigate the impact of SAP on stroke outcome depending on whether or not it conforms to mCDC criteria. Our secondary objective was to identify the responsible factors for antibiotic initiation in stroke patients. Methods We conducted a prospective, multicenter, observational study of ischemic stroke patients with moderate to severe stroke (NIHSS≥4) admitted within 24 h. For 7 days, mCDC criteria were assessed daily, and infections and antibiotics were recorded. Pneumonias were divided into those fulfilling mCDC criteria (mCDC-SAP) or not (other pneumonias, OPn). The effect of each type of pneumonia on 3-month outcome was evaluated in separated logistic regression models. Factors associated with antibiotic initiation were explored using a random forest analysis. Results Of the 342 patients studied, infections were diagnosed in 72 (21.6%), including 39 (11.7%) cases of pneumonia. Of them, 25 (7.5%) fulfilled mCDC criteria. Antibiotics were used in 92% of mCDC-SAP and 64.3% of OPn. In logistic regression analysis, mCDC-SAP, but not OPn, was an independent predictor of poor outcome [OR, 4.939 (1.022-23.868)]. The random forest analysis revealed that fever had the highest importance for antibiotic initiation. Interpretation The mCDC criteria might be useful for detecting clinically relevant SAP, which is associated with poor outcomes. Isolated signs of infection were more important for antibiotic initiation than compliance with pre-defined criteria. Therefore, adherence to mCDC criteria might result in antibiotic saving without compromising clinical outcome.
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Affiliation(s)
- Neus Rabaneda-Lombarte
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Júlia Faura
- Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Garbiñe Ezcurra-Díaz
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Marta Álvarez-Larruy
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | | | | | | | | | | | | | | | | | - Mònica Millán
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Marta Rubiera
- Hospital Universitari Vall d’Hebrón, Barcelona, Spain
| | - Laura Dorado
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Joan Montaner
- Vall d'Hebrón Institute of Research, Barcelona, Spain
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Alejandro Bustamante
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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Kara N, Iweka CA, Blacher E. Chrono-Gerontology: Integrating Circadian Rhythms and Aging in Stroke Research. Adv Biol (Weinh) 2023; 7:e2300048. [PMID: 37409422 DOI: 10.1002/adbi.202300048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/14/2023] [Indexed: 07/07/2023]
Abstract
Stroke is a significant public health concern for elderly individuals. However, the majority of pre-clinical studies utilize young and healthy rodents, which may result in failure of candidate therapies in clinical trials. In this brief review/perspective, the complex link between circadian rhythms, aging, innate immunity, and the gut microbiome to ischemic injury onset, progression, and recovery is discussed. Short-chain fatty acids and nicotinamide adenine dinucleotide+ (NAD+ ) production by the gut microbiome are highlighted as key mechanisms with profound rhythmic behavior, and it is suggested to boost them as prophylactic/therapeutic approaches. Integrating aging, its associated comorbidities, and circadian regulation of physiological processes into stroke research may increase the translational value of pre-clinical studies and help to schedule the optimal time window for existing practices to improve stroke outcome and recovery.
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Affiliation(s)
- Nirit Kara
- Department of Biological Chemistry, The Alexander Silberman Institute of Life Sciences, The Hebrew University of Jerusalem, Edmond J. Safra Campus Givat-Ram, Jerusalem, 9190401, Israel
| | - Chinyere Agbaegbu Iweka
- Department of Neurology & Neurological Sciences, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Eran Blacher
- Department of Biological Chemistry, The Alexander Silberman Institute of Life Sciences, The Hebrew University of Jerusalem, Edmond J. Safra Campus Givat-Ram, Jerusalem, 9190401, Israel
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4
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Pluta R, Jabłoński M, Januszewski S, Czuczwar SJ. Crosstalk between the aging intestinal microflora and the brain in ischemic stroke. Front Aging Neurosci 2022; 14:998049. [PMID: 36275012 PMCID: PMC9582537 DOI: 10.3389/fnagi.2022.998049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022] Open
Abstract
Aging is an inevitable phenomenon experienced by animals and humans, and its intensity varies from one individual to another. Aging has been identified as a risk factor for neurodegenerative disorders by influencing the composition of the gut microbiota, microglia activity and cognitive performance. The microbiota-gut-brain axis is a two-way communication path between the gut microbes and the host brain. The aging intestinal microbiota communicates with the brain through secreted metabolites (neurotransmitters), and this phenomenon leads to the destruction of neuronal cells. Numerous external factors, such as living conditions and internal factors related to the age of the host, affect the condition of the intestinal microflora in the form of dysbiosis. Dysbiosis is defined as changes in the composition and function of the gut microflora that affect the pathogenesis, progress, and response to treatment of a disease entity. Dysbiosis occurs when changes in the composition and function of the microbiota exceed the ability of the microflora and its host to restore equilibrium. Dysbiosis leading to dysfunction of the microbiota-gut-brain axis regulates the development and functioning of the host’s nervous, immune, and metabolic systems. Dysbiosis, which causes disturbances in the microbiota-gut-brain axis, is seen with age and with the onset of stroke, and is closely related to the development of risk factors for stroke. The review presents and summarizes the basic elements of the microbiota-gut-brain axis to better understand age-related changes in signaling along the microbiota-gut-brain axis and its dysfunction after stroke. We focused on the relationship between the microbiota-gut-brain axis and aging, emphasizing that all elements of the microbiota-gut-brain axis are subject to age-related changes. We also discuss the interaction between microbiota, microglia and neurons in the aged individuals in the brain after ischemic stroke. Finally, we presented preclinical and clinical studies on the role of the aged microbiota-gut-brain axis in the development of risk factors for stroke and changes in the post-stroke microflora.
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Affiliation(s)
- Ryszard Pluta
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
- *Correspondence: Ryszard Pluta,
| | - Mirosław Jabłoński
- Department of Rehabilitation and Orthopedics, Medical University of Lublin, Lublin, Poland
| | - Sławomir Januszewski
- Laboratory of Ischemic and Neurodegenerative Brain Research, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
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Abstract
The microbiota-gut-brain-axis (MGBA) is a bidirectional communication network between gut microbes and their host. Many environmental and host-related factors affect the gut microbiota. Dysbiosis is defined as compositional and functional alterations of the gut microbiota that contribute to the pathogenesis, progression and treatment responses to disease. Dysbiosis occurs when perturbations of microbiota composition and function exceed the ability of microbiota and its host to restore a symbiotic state. Dysbiosis leads to dysfunctional signaling of the MGBA, which regulates the development and the function of the host's immune, metabolic, and nervous systems. Dysbiosis-induced dysfunction of the MGBA is seen with aging and stroke, and is linked to the development of common stroke risk factors such as obesity, diabetes, and atherosclerosis. Changes in the gut microbiota are also seen in response to stroke, and may impair recovery after injury. This review will begin with an overview of the tools used to study the MGBA with a discussion on limitations and potential experimental confounders. Relevant MGBA components are introduced and summarized for a better understanding of age-related changes in MGBA signaling and its dysfunction after stroke. We will then focus on the relationship between the MGBA and aging, highlighting that all components of the MGBA undergo age-related alterations that can be influenced by or even driven by the gut microbiota. In the final section, the current clinical and preclinical evidence for the role of MGBA signaling in the development of stroke risk factors such as obesity, diabetes, hypertension, and frailty are summarized, as well as microbiota changes with stroke in experimental and clinical populations. We conclude by describing the current understanding of microbiota-based therapies for stroke including the use of pre-/pro-biotics and supplementations with bacterial metabolites. Ongoing progress in this new frontier of biomedical sciences will lead to an improved understanding of the MGBA's impact on human health and disease.
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Affiliation(s)
- Pedram Honarpisheh
- Department of Neurology, University of Texas McGovern Medical School, Houston (P.H., L.D.M.)
| | - Robert M Bryan
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX (R.M.B.)
| | - Louise D McCullough
- Department of Neurology, University of Texas McGovern Medical School, Houston (P.H., L.D.M.)
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Bartolo M, Zucchella C, Aabid H, Valoriani B, Copetti M, Fontana A, Intiso D, Mancuso M. Impact of healthcare-associated infections on functional outcome of severe acquired brain injury during inpatient rehabilitation. Sci Rep 2022; 12:5245. [PMID: 35347197 PMCID: PMC8960831 DOI: 10.1038/s41598-022-09351-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
To describe healthcare-associated infections in inpatient neuro-rehabilitation and their impact on functional outcome, a multicenter observational study with severe acquired brain injury (sABI) patients was performed. Patients were divided into infected (INF-group) or not infected (noINF-group) and assessed at admission and discharge, by means of the Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), the Disability Rating Scale (DRS), and the modified Barthel Index (mBI). One hundred-nineteen patients were included in the INF-group, and 109 in the noINF-group. Culture specimens were found positive for bloodstream (43.8%), respiratory tract (25.7%), urinary tract (16.2%), gastro-intestinal system (8.6%) and skin (2.4%) infections. Multiple microorganisms were the most frequent (58.1%) and 55.5% of patients needed functional isolation due to multidrug resistant germs. The functional status of both groups improved after rehabilitation, but multivariable analyses showed that the INF-group showed a significantly lower gain to GCS (p = 0.008), DRS (p = 0.020) and mBI (p = 0.021) compared to the noINF-group. Length of stay (LOS) and number of skipped rehabilitative sessions were not statistically different between the groups; mortality rate was significantly higher in the INF-group (p = 0.04). Infected sABI patients showed longer LOS, significant increased mortality, and a lower functional outcome than not infected patients.
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Affiliation(s)
- Michelangelo Bartolo
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Via Bologna 1, 24040, Zingonia/Ciserano, BG, Italy.
| | | | - Hend Aabid
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Via Bologna 1, 24040, Zingonia/Ciserano, BG, Italy
| | - Beatrice Valoriani
- Medicine Unit, Ospedali Riuniti della Valdichiana, Nottola Hospital, Siena, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Domenico Intiso
- Unit of Neurorehabilitation and Rehabilitation Medicine, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, FG, Italy
| | - Mauro Mancuso
- Medicine Unit, Ospedali Riuniti della Valdichiana, Nottola Hospital, Siena, Italy
- Physical and Rehabilitative Medicine Unit, NHS-USL Toscana Sud Est, Grosseto, Italy
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7
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Muhl H, Roth C, Schröter A, Politi M, Alexandrou M, Dahl J, Gindorf S, Papanagiotou P, Kastrup A. Pneumonia in Acute Ischemic Stroke Patients with Proximal Occlusions within the Anterior Circulation after Endovascular Therapy or Systemic Thrombolysis. J Clin Med 2022; 11:jcm11030482. [PMID: 35159933 PMCID: PMC8836980 DOI: 10.3390/jcm11030482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 02/01/2023] Open
Abstract
While endovascular treatment (ET) improves clinical outcomes in patients with proximal vessel occlusions compared to thrombolysis (IVT), the impact of ET on the frequency of stroke-associated pneumonia (SAP) is uncertain. We compared the rates of SAP in patients with large vessel occlusions in the anterior circulation after IVT or ET. We also determined risk factors for SAP, as well as the impact of SAP on early clinical outcomes. A total of 544 patients were treated with IVT, and 1061 patients received ET (with or without IVT). The rates of SAP did not differ significantly between ET (217/1061; 20%) and IVT (100/544; 18%) (p = 0.3). Overall, the occurrence of SAP was significantly associated with mortality and a poor clinical outcome. In the multivariable regression analysis, age, sex, the presence of dysphagia, early signs of ischemia on imaging and a history of stroke and mechanical ventilation were all significantly associated with the occurrence of SAP. In patients with large vessel occlusions, the introduction of ET did not result in lower rates of SAP compared with IVT. There is an ongoing need to reduce the rates of SAP in this patient population, for which the risk factors found here could become useful.
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Affiliation(s)
- Henning Muhl
- Department of Neurology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (H.M.); (A.S.); (J.D.); (S.G.)
| | - Christian Roth
- Department of Neuroradiology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (C.R.); (M.P.); (M.A.); (P.P.)
| | - Andreas Schröter
- Department of Neurology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (H.M.); (A.S.); (J.D.); (S.G.)
| | - Maria Politi
- Department of Neuroradiology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (C.R.); (M.P.); (M.A.); (P.P.)
| | - Maria Alexandrou
- Department of Neuroradiology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (C.R.); (M.P.); (M.A.); (P.P.)
| | - Janina Dahl
- Department of Neurology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (H.M.); (A.S.); (J.D.); (S.G.)
| | - Susanne Gindorf
- Department of Neurology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (H.M.); (A.S.); (J.D.); (S.G.)
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (C.R.); (M.P.); (M.A.); (P.P.)
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, St.-Jürgen-Street 1, 28177 Bremen, Germany; (H.M.); (A.S.); (J.D.); (S.G.)
- Department of Neurology, University of Göttingen, Robert-Koch-Street 40, 37075 Göttingen, Germany
- Correspondence:
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Tung IM, Barlas RS, Vart P, Bettencourt-Silva JH, Clark AB, Sawanyawisuth K, Kongbunkiat K, Kasemsap N, Tiamkao S, Myint PK. Association of chronic kidney disease with outcomes in acute stroke. Acta Neurol Belg 2021; 121:1241-1246. [PMID: 32661738 PMCID: PMC8443515 DOI: 10.1007/s13760-020-01416-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 06/29/2020] [Indexed: 12/31/2022]
Abstract
Previous studies have found an association between chronic kidney disease and poor outcomes in stroke patients. However, there is a paucity of literature evaluating this association by stroke type. We therefore aimed to explore the association between CKD and stroke outcomes according to type of stroke. The data consisting of 594,681 stroke patients were acquired from Universal Coverage Health Security Insurance Scheme Database in Thailand. Binary logistic regression was used to assess the relationship of CKD and outcomes, which were as follows; in-hospital mortality, long length of stay (>3 days), pneumonia, sepsis, respiratory failure and myocardial infarction. Results: after fully adjusting for covariates, CKD was associated with increased odds of in-hospital mortality in patients with ischemic (OR 1.32; 95% CI = 1.27–1.38), haemorrhagic (OR 1.31; 95% CI = 1.24–1.39), and other undetermined stroke type (OR 1.44; 95% CI = 1.21–1.73). CKD was found to be associated with increased odds of pneumonia, sepsis, respiratory failure and myocardial infarction in ischaemic stroke. While CKD was found to be associated with increase odds of sepsis, respiratory failure, and myocardial infarction, decrease odds of pneumonia was observed in patients with haemorrhagic stroke. In other undetermined stroke type, CKD was found to only be associated with increase odds of sepsis and respiratory failure, while there is no significant association of CKD and increase or decrease odds with pneumonia and myocardial infarction. CKD was associated with poor outcomes in all stroke types. CKD should be considered as part of stroke prognosis as well as identifying at risk patient population for in-hospital complications.
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Ndakotsu A, Myneni R, Iqbal A, Grewal AS, Abubacker AP, Vivekanandan G, Chawla HV, Khan S. Prophylactic Antibiotics, the Mediator of Post-Stroke Infections: A Systematic Review. Cureus 2021; 13:e15055. [PMID: 34150402 PMCID: PMC8208172 DOI: 10.7759/cureus.15055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/15/2021] [Indexed: 11/28/2022] Open
Abstract
Infections frequently complicate an acute stroke and have been associated with an unfavorable prognosis among patients. The use of prophylactic antibiotics seems rational, however, its efficacy has remained obscure. This systematic review aims to offer more clarity to this established dilemma. PubMed and Google Scholar were explored to gain access to studies on post-stroke infection. A systematic review was carried out to analyze how profitable it would be to offer preventive antibiotics immediately after an acute stroke. Five randomized control trials were obtained and analyzed the efficacy of antibiotics in acute stroke according to their intrinsic effects on the infection rate, functionality, and mortality benefits. Based on our findings, we discovered that antibiotics reduce the onset of early infections, especially urinary tract infections, but have absolutely no effect on the functionality and offer no mortality benefit. These results were emphatically shown in two large, open-labeled randomized controlled trials involved in this systematic review. Prophylactic antibiotics provide no additional benefits to the standard of care and should not be used following an acute stroke. They may decrease the incidence of acute infections, especially urinary tract infections, but have no effects on functional outcome and mortality.
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Affiliation(s)
- Andrew Ndakotsu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Revathi Myneni
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aimen Iqbal
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amit S Grewal
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ansha P Abubacker
- Emergency Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Govinathan Vivekanandan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Harsh V Chawla
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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10
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Dylla L, Herson PS, Poisson SN, Rice JD, Ginde AA. Association Between Chronic Inflammatory Diseases and Stroke-Associated Pneumonia - An Epidemiological Study. J Stroke Cerebrovasc Dis 2021; 30:105605. [PMID: 33482567 PMCID: PMC7946738 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/23/2020] [Accepted: 01/02/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Pneumonia, the most common post-acute ischemic stroke (AIS) infection, accounts for up to 30% of deaths after a stroke. Multiple chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and inflammatory bowel disease, are associated with increased risk of stroke and stroke morbidity. This study assessed the relationship between chronic inflammatory diseases and stroke-associated pneumonia (SAP). METHODS Using data from the 2015-2017 National Inpatient Sample, we classified hospital discharges with a diagnosis of AIS as having ulcerative colitis, Crohn's disease, rheumatoid arthritis, psoriasis, systemic lupus erythematosus, other chronic inflammatory diseases, multiple chronic inflammatory diseases, or none. With multivariable logistic regression, we assessed for associations between chronic inflammatory disease and in-hospital SAP or death. RESULTS Among AIS discharges, there was a decreased risk of SAP among those with psoriasis or other chronic inflammatory diseases (adjusted odds ratio (aOR) 0.70, 95%CI 0.63-0.99; aOR 0.64, 95%CI, 0.46-0.89, respectively), compared to those without psoriasis and without other chronic inflammatory disease, respectively. Rheumatoid arthritis, psoriasis, and other chronic inflammatory diseases were associated with reduced in-hospital mortality (aOR 0.89, 95%CI 0.78-1.00; aOR 0.77, 95%CI 0.59-1.00; aOR 0.69, 95%CI 0.50-0.94, respectively). CONCLUSIONS The risk of SAP and in-hospital mortality varies by chronic inflammatory disease - psoriasis and other chronic inflammatory diseases are associate with reduced rates of SAP, whereas rheumatoid arthritis, psoriasis and other chronic inflammatory disease were associated with reduced in-hospital mortality. Further investigations are needed to determine a relationship between the potential role of immunomodulation and the reduction in SAP and mortality in chronic inflammatory diseases.
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Affiliation(s)
- Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Ave., B215, Aurora, CO 80045, United States.
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado School of Medicine, United States
| | - Sharon N Poisson
- Department of Neurology, University of Colorado School of Medicine, United States
| | - John D Rice
- Department of Biostatistics and Informatics, Colorado School of Public Health, United States
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Ave., B215, Aurora, CO 80045, United States
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Hu D, Ding C, Jiang X, Xiao J, Li C, Zhang L, Li T, Ji Y, Peng Y, Luo X, Sheng L, Wang Q, Wu H. Elevated Levels of Inflammation Markers Predict Poor Outcomes in Acute Ischemic Stroke Patients After Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2021; 30:105587. [PMID: 33450606 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Inflammation is associated with the occurrence and prognosis of ischemic stroke. The aim of this study was to evaluate the association between inflammatory biomarkers and the short-term clinical outcomes of acute ischemic stroke (AIS) patients after intravenous thrombolysis (IVT). MATERIALS AND METHODS A total of 208 AIS patients treated with IVT were enrolled in this retrospective study. Blood tests of inflammatory biomarkers, including the leukocyte count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio and high-sensitivity C-reactive protein level, were conducted within 24 h after IVT. The primary outcome was decent functional recovery (DFR) [modified Rankin Scale score (mRS) of 0-2] at 3 months. The secondary outcomes included symptomatic intracranial hemorrhage and 3-month mortality. A multivariate analysis was performed to evaluate the associations between inflammatory biomarkers and 3-month clinical outcomes. RESULTS At 3 months follow-up, 113 (62.2%) patients achieved DFR. As compared to patients with DFR, patients without DFR had higher leukocyte counts (8.5 ± 2.4 × 109/L versus 6.9 ± 1.7 × 109/L, P=0.000), neutrophil counts (6.1 ± 2.3 × 109/L versus 4.6±1.7 × 109/L, P=0.000) and neutrophil-to-lymphocyte ratio (4.6 ± 2.4 versus 3.3 ± 1.9, P=0.000). After adjusting for the stroke subtype, severity of stroke, and medical history, the leukocyte count and neutrophil count remained significantly correlated with non-DFR (adjusted odds ratio [OR] 1.488; 95% confidence interval [CI], 1.247-1.776; P=0.000 and adjusted OR 1.522; 95% CI, 1.269-1.826; P=0.000, respectively). CONCLUSIONS This study demonstrates that increased levels of inflammatory biomarkers are independently associated with poor outcomes at 3 months in AIS patients treated with IVT.
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Affiliation(s)
- Dan Hu
- School of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China; Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Caixia Ding
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Xuemei Jiang
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Jing Xiao
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Chuanyou Li
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Lankun Zhang
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Tingting Li
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Yun Ji
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Yuan Peng
- Department of Rehabilitation Medicine, Guangzhou First People's Hospital, Guangzhou, Guangdong, China
| | - Xun Luo
- Shenzhen Dapeng New District Nan'ao People's Hospital, Shenzhen, China; Kerry Rehabilitation Medicine Research Institute, Shenzhen, China
| | - Lei Sheng
- Department of Neurology, The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Qingmei Wang
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, Boston, MA, United States.
| | - Haoxin Wu
- School of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China.
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12
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Lipopolysaccharide-induced sepsis-like state compromises post-ischemic neurological recovery, brain tissue survival and remodeling via mechanisms involving microvascular thrombosis and brain T cell infiltration. Brain Behav Immun 2021; 91:627-638. [PMID: 33122024 DOI: 10.1016/j.bbi.2020.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/04/2020] [Accepted: 10/13/2020] [Indexed: 02/03/2023] Open
Abstract
Sepsis predisposes for poor stroke outcome. This association suggests that sepsis disturbs post-ischemic tissue survival and brain remodeling. To elucidate this link, we herein exposed mice to 30 min intraluminal middle cerebral artery occlusion (MCAO) and induced a sepsis-like state at 72 h post-ischemia by intraperitoneal delivery of Escherichia coli lipopolysaccharide (LPS; three doses of 0.1 or 1 mg/kg, separated by 6 h), a major component of the bacterium's outer membrane. Neurological recovery, ischemic injury, brain remodeling and immune responses were evaluated over up to 56 days post-sepsis (dps) by behavioral tests, immunohistochemistry and flow cytometry. Delivery of 1 mg/kg but not 0.1 mg/kg LPS reduced rectal temperature over 48 h by up to 3.4 ± 3.1 °C, increased general and focal neurological deficits in the Clark score over 72 h and increased motor-coordination deficits in the tight rope test over up to 21 days. Notably, 1 mg/kg, but not 0.1 mg/kg LPS increased intercellular adhesion molecule-1 abundance on ischemic microvessels, increased microvascular thrombosis and increased patrolling monocyte and T cell infiltrates in ischemic brain tissue at 3 dps. Infarct volume was increased by 1 mg/kg, but not 0.1 mg/kg LPS at 3 dps (that is, 6 days post-MCAO), as was brain atrophy at 28 and 56 dps. Microglial activation in ischemic brain tissue, evaluated by morphology analysis of Iba-1 immunostainings, was transiently increased by 0.1 and 1 mg/kg LPS at 3 dps. Our data provide evidence that neurological recovery and brain remodeling are profoundly compromised in the ischemic brain post-sepsis as a consequence of cerebral thromboinflammation.
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13
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Bartolo M, Zucchella C, Aabid H, Valoriani B, Mancuso M, Intiso D. Healthcare-Associated Infections in Subjects With Severe Acquired Brain Injury: The Effect of Microbial Colonization on the Functional Outcome. Data From a Multicenter Observational Study. Front Neurol 2020; 11:563275. [PMID: 33240197 PMCID: PMC7683713 DOI: 10.3389/fneur.2020.563275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Hospital-acquired infections (HAIs) and microbial colonization are a worldwide serious threat for human health. Neurological patients with infections who undergo rehabilitation have a significantly poor recovery. The effect of microbial colonization on the functional outcome in severe acquired brain injury (sABI) subjects is still unclear. Aim: The aim of this multicenter observational study was to describe the clinical impact of HAIs and colonization on the functional outcome of sABI subjects admitted to inpatient neurorehabilitation. Methods: Patients were assigned to three groups: infected (INF), not infected (noINF), and colonized (COL). The Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale, Disability Rating Scale, and modified Barthel Index (mBI) assessments were performed both at admission and discharge. Results: Two hundred sixty-five (92 female/173 male) patients were enrolled: 134 were assigned to INF, 63 to COL, and 68 to noINF. In the INF group, 231 culture specimens were found positive for bloodstream (44.2%), respiratory tract (25.5%), urinary tract (18.6%), gastrointestinal tract (8.3%), skin (3%), and cerebrospinal fluid (0.4%) infections. After rehabilitation, all groups showed a significant improvement in all assessment tests, except for the noINF group that did not show any improvement in GCS. Both noINF and COL groups showed a significantly higher gain in mBI than the INF group (p = 0.000). The COL group showed a significantly higher gain than the noINF group in GCS (p = 0.001). A significantly lower improvement was detected in the INF group than the COL and noINF groups. The rate of patients who needed functional isolation was higher in the INF group than the COL group. Length of stay (LOS) (in days) was 56 ± 50.7, 88.3 ± 55, and 101.3 ± 73.6 for noINF, INF, and COL groups, respectively. The number of deaths in the INF group was significantly higher (24.6%) than the noINF group (7.4%) (p = 0.005) and comparable to the COL group (19%). Conclusion: Colonized sABI patients obtained a similar functional outcome to that of subjects who had no infections, even if they needed a significantly higher LOS.
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Affiliation(s)
- Michelangelo Bartolo
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Bergamo, Italy
| | | | - Hend Aabid
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA Zingonia, Bergamo, Italy
| | - Beatrice Valoriani
- Medicine Unit, Ospedali Riuniti della Valdichiana, Presidio di Nottola, Siena, Italy
| | - Mauro Mancuso
- Tuscany Rehabilitation Clinic, Arezzo, Italy.,Physical and Rehabilitative Medicine Unit, NHS-USL Toscana Sud Est, Grosseto, Italy
| | - Domenico Intiso
- Unit of Neurorehabilitation and Rehabilitation Medicine, Istituto di Ricovero e Cura a Carattere Scientifico "Casa Sollievo della Sofferenza, " Foggia, Italy
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14
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Pilato F, Silva S, Valente I, Distefano M, Broccolini A, Brunetti V, Caliandro P, Marca GD, Di Iorio R, Frisullo G, Monforte M, Morosetti R, Piano C, Calandrelli R, Capone F, Alexandre A, Pedicelli A, Colosimo C, Caricato A. Predicting Factors of Functional Outcome in Patients with Acute Ischemic Stroke Admitted to Neuro-Intensive Care Unit-A Prospective Cohort Study. Brain Sci 2020; 10:brainsci10120911. [PMID: 33256264 PMCID: PMC7761293 DOI: 10.3390/brainsci10120911] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/16/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023] Open
Abstract
Although thrombectomy is beneficial for most stroke patients with large vessel occlusion (LVO), it has added new issues in acute management due to intensive care support. In this prospective cohort study, we described the patients admitted to our neuro-intensive care unit (NICU) after thrombectomy in order to assess factors linked to functional outcomes. The outcome was independency assessed for stroke patients consecutively admitted to NICU for an ischemic stroke due to LVO of the anterior cerebral circulation that underwent intra-arterial mechanical thrombectomy (IAMT), either in combination with intravenous thrombolysis (IVT) in eligible patients or alone in patients with contraindications for IVT. Overall, 158 patients were enrolled. IVT (odds ratio (OR), 3.78; 95% confidence interval (CI), 1.20–11.90; p = 0.023) and early naso-gastric tube removal (OR, 3.32; 95% CI, 1.04–10.59 p = 0.042) were associated with good outcomes, whereas a high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.72 for each point of increase; 95% CI, 0.61–0.85; p < 0.001) was a predictor of poor outcomes at 3 months. Older age (OR, 0.95 for each year of increase; 95% CI, 0.92–0.99; p = 0.020) and hemorrhagic transformation (OR, 0.31; 95% CI, 0.11–0.84; p = 0.022) were predictors of poor outcomes after IAMT, whereas a modified Treatment in Cerebral Infarction (mTICI) score of 2b/3 was a predictor of good outcomes (OR, 7.86; 95% CI, 1.65–37.39; p = 0.010) at 6 months. Our results show that acute stroke patients with LVO who require NICU management soon after IAMT may show specific clinical factors influencing short- and long-term neurologic independency.
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Affiliation(s)
- Fabio Pilato
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
- Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy;
- Correspondence: ; Tel.: +39-06-30151
| | - Serena Silva
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Iacopo Valente
- UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (I.V.); (R.C.); (A.A.); (A.P.); (C.C.)
| | - Marisa Distefano
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Aldobrando Broccolini
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Valerio Brunetti
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Pietro Caliandro
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Giacomo Della Marca
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Riccardo Di Iorio
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Giovanni Frisullo
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Mauro Monforte
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Roberta Morosetti
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Carla Piano
- UOC Neurologia, Dipartimento Scienze dell’invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.D.); (A.B.); (V.B.); (P.C.); (G.D.M.); (R.D.I.); (G.F.); (M.M.); (R.M.); (C.P.)
| | - Rosalinda Calandrelli
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Fioravante Capone
- Unit of Neurology, Neurophysiology, Department of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy;
| | - Andrea Alexandre
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Alessandro Pedicelli
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
| | - Cesare Colosimo
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
| | - Anselmo Caricato
- UOC Anestesia Rianimazione, Terapia Intensiva e Tossicologia Clinica, Dipartimento Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.S.); (A.C.)
- Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
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15
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Naito Y, Kamiya M, Morishima N, Ishikawa T. Association between out-of-bed mobilization and complications of immobility in acute phase of severe stroke: A retrospective observational study. J Stroke Cerebrovasc Dis 2020; 29:105112. [PMID: 32912565 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Medical complications often occur, particularly in the acute phase of severe stroke, and lead to poor outcomes. However, it is unclear whether out-of-bed mobilization (OM) reduces such complications or not in the acute phase of severe stroke. Thus, we investigated the association between OM and complications of immobility in the acute phase of severe stroke. METHODS We enrolled 407 patients diagnosed with ischemic stroke or intracerebral hemorrhage and patients with modified Rankin Scale 5 at discharge in this study. Patients were divided into two groups: OM (303 patients) and bed rest (BR; 104 patients) at discharge based on their medical records. Complications of immobility (such as pneumonia, urinary tract infection, pressure sore, and falls) during hospitalization in each group were recorded. RESULTS The total complication rate of immobility, incidence of pneumonia, and the incidence of pressure sores were significantly lower in the OM group than in the BR group [60.7% vs. 88.5%, 45.5% vs. 62.5%, and 3.6% vs. 12.5%; odds ratio, 0.20, 0.50, and 0.26; and 95% confidence intervals, 0.11-0.39, 0.32-0.79, and 0.11-0.61, respectively]. Urinary tract infection and falls did not differ significantly between the two groups. CONCLUSIONS In the acute phase of severe stroke, OM was significantly associated with a lower risk of total complication rate of immobility, incidence of pneumonia, and incidence of pressure sore without increasing falls.
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Affiliation(s)
- Yoshinori Naito
- Rehabilitation center, Toyohashi Municipal Hospital, Toyohashi, Aotakecho, Japan.
| | - Masataka Kamiya
- Rehabilitation center, Toyohashi Municipal Hospital, Toyohashi, Aotakecho, Japan.
| | - Naohito Morishima
- Rehabilitation center, Toyohashi Municipal Hospital, Toyohashi, Aotakecho, Japan.
| | - Tomoji Ishikawa
- Rehabilitation Department, Toyohashi Municipal Hospital, Toyohashi, Aotakecho, Japan.
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16
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Zera KA, Buckwalter MS. The Local and Peripheral Immune Responses to Stroke: Implications for Therapeutic Development. Neurotherapeutics 2020; 17:414-435. [PMID: 32193840 PMCID: PMC7283378 DOI: 10.1007/s13311-020-00844-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The immune response to stroke is an exciting target for future stroke therapies. Stroke is a leading cause of morbidity and mortality worldwide, and clot removal (mechanical or pharmacological) to achieve tissue reperfusion is the only therapy currently approved for patient use. Due to a short therapeutic window and incomplete effectiveness, however, many patients are left with infarcted tissue that stimulates inflammation. Although this is critical to promote repair, it can also damage surrounding healthy brain tissue. In addition, acute immunodepression and subsequent infections are common and are associated with worse patient outcomes. Thus, the acute immune response is a major focus of researchers attempting to identify ways to amplify its benefits and suppress its negative effects to improve short-term recovery of patients. Here we review what is known about this powerful process. This includes the role of brain resident cells such as microglia, peripherally activated cells such as macrophages and neutrophils, and activated endothelium. The role of systemic immune activation and subsequent immunodepression in the days after stroke is also discussed, as is the chronic immune responses and its effects on cognitive function. The biphasic role of inflammation, as well as complex timelines of cell production, differentiation, and trafficking, suggests that the relationship between the acute and chronic phases of stroke recovery is complex. Gaining a more complete understanding of this intricate process by which inflammation is initiated, propagated, and terminated may potentially lead to therapeutics that can treat a larger population of stroke patients than what is currently available. The immune response plays a critical role in patient recovery in both the acute and chronic phases after stroke. In patients, the immune response can be beneficial by promoting repair and recovery, and also detrimental by propagating a pro-inflammatory microenvironment. Thus, it is critical to understand the mechanisms of immune activation following stroke in order to successfully design therapeutics.
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Affiliation(s)
- Kristy A Zera
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA.
- Department of Neurosurgery, Stanford Univeristy School of Medicine, Stanford, CA, USA.
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17
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Ouyang M, Billot L, Song L, Wang X, Roffe C, Arima H, Lavados PM, Hackett ML, Olavarría VV, Muñoz-Venturelli P, Middleton S, Pontes-Neto OM, Lee TH, Watkins CL, Robinson TG, Anderson CS. Prognostic significance of early urinary catheterization after acute stroke: Secondary analyses of the international HeadPoST trial. Int J Stroke 2020; 16:200-206. [PMID: 32075569 DOI: 10.1177/1747493020908140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND An indwelling urinary catheter (IUC) is often inserted to manage bladder dysfunction, but its impact on prognosis is uncertain. We aimed to determine the association of IUC use on clinical outcomes after acute stroke in the international, multi-center, cluster crossover, Head Positioning in Acute Stroke Trial (HeadPoST). METHODS Data were analyzed on HeadPoST participants (n = 11,093) randomly allocated to the lying-flat or sitting-up head position. Binomial, logistic regression, hierarchical mixed models were used to determine associations of early insertion of IUC within seven days post-randomization and outcomes of death or disability (defined as "poor outcome," scores 3-6 on the modified Rankin scale) and any urinary tract infection at 90 days with adjustment of baseline and post-randomization management covariates. RESULTS Overall, 1167 (12%) patients had an IUC, but the frequency and duration of use varied widely across patients in different regions. IUC use was more frequent in older patients, and those with vascular comorbidity, greater initial neurological impairment (on the National Institutes of Health Stroke Scale), and intracerebral hemorrhage as the underlying stroke type. IUC use was independently associated with poor outcome (adjusted odds ratio (aOR): 1.40, 95% confidence interval (CI): 1.13-1.74), but not with urinary tract infection after adjustment for antibiotic treatment and stroke severity at hospital separation (aOR: 1.13, 95% CI: 0.59-2.18). The number exposed to IUC for poor outcome was 13. CONCLUSIONS IUC use is associated with a poor outcome after acute stroke. Further studies are required to inform appropriate use of IUC.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia
| | - Christine Roffe
- Department of Neurosciences, 105646Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Hisatomi Arima
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Pablo M Lavados
- Departmento de Neurologia and Psiquiatria, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Vitacura, Chile
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
| | - Verónica V Olavarría
- Departmento de Neurologia and Psiquiatria, Clínica Alemana de Santiago, Servicio de Neurología, Unidad de Neurología Vascular, Vitacura, Chile
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,Center for Clinical Studies, School of Medicine-Clínica Alemana, ICIM, 28071Universidad del Desarrollo, Santiago, Chile
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia, Australian Catholic University, Sydney, Australia
| | - Octavio M Pontes-Neto
- Stroke Service-Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan
| | - Caroline L Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, Lancashire, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, 7800University of New South Wales, Sydney, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China.,Center for Clinical Studies, School of Medicine-Clínica Alemana, ICIM, 28071Universidad del Desarrollo, Santiago, Chile.,Neurology Department, 2205Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia.,Heart Health Research Center, Beijing, China
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18
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Parikh NS, Merkler AE, Iadecola C. Inflammation, Autoimmunity, Infection, and Stroke: Epidemiology and Lessons From Therapeutic Intervention. Stroke 2020; 51:711-718. [PMID: 32078460 DOI: 10.1161/strokeaha.119.024157] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Neal S Parikh
- From the Department of Neurology, Columbia University Medical College (N.S.P.), Weill Cornell Medicine, New York, NY.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY.,Department of Neurology (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY.,Department of Neurology (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY.,Department of Neurology (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY
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19
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Tørnes M, McLernon DJ, Bachmann MO, Musgrave SD, Warburton EA, Potter JF, Myint PK. Hospital-Level Variations in Rates of Inpatient Urinary Tract Infections in Stroke. Front Neurol 2019; 10:827. [PMID: 31447761 PMCID: PMC6691802 DOI: 10.3389/fneur.2019.00827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Michelle Tørnes
- Ageing Clinical and Experimental Research Group, School of Medicine, Medical Sciences and Nutrition, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - David J McLernon
- Medical Statistics Team, School of Medicine, Medical Sciences and Nutrition, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Max O Bachmann
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Stanley D Musgrave
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | | | - John F Potter
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research Group, School of Medicine, Medical Sciences and Nutrition, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, United Kingdom
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20
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Mengel A, Ulm L, Hotter B, Harms H, Piper SK, Grittner U, Montaner J, Meisel C, Meisel A, Hoffmann S. Biomarkers of immune capacity, infection and inflammation are associated with poor outcome and mortality after stroke - the PREDICT study. BMC Neurol 2019; 19:148. [PMID: 31269910 PMCID: PMC6607590 DOI: 10.1186/s12883-019-1375-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/23/2019] [Indexed: 02/20/2023] Open
Abstract
Background Almost 40% of stroke patients have a poor outcome at 3 months after the index event. Predictors for stroke outcome in the early acute phase may help to tailor stroke treatment. Infection and inflammation are considered to influence stroke outcome. Methods In a prospective multicenter study in Germany and Spain, including 486 patients with acute ischemic stroke, we used multivariable regression analysis to investigate the association of poor outcome with monocytic HLA-DR (mHLA-DR) expression, interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha) and lipopolysaccharide-binding protein (LBP) as markers for immunodepression, inflammation and infection. Outcome was assessed at 3 months after stroke via a structured telephone interview using the modified Rankin Scale (mRS). Poor outcome was defined as a mRS score of 3 or higher which included death. Furthermore, a time-to-event analysis for death within 3 months was performed. Results Three-month outcome data was available for 391 patients. Female sex, older age, diabetes mellitus, atrial fibrillation, stroke-associated pneumonia (SAP) and higher National Institute of Health Stroke Scale (NIHSS) score as well as lower mHLA-DR levels, higher IL-6 and LBP-levels at day 1 were associated with poor outcome at 3 months in bivariate analysis. Furthermore, multivariable analysis revealed that lower mHLA-DR expression was associated with poor outcome. Female sex, older age, atrial fibrillation, SAP, higher NIHSS score, lower mHLA-DR expression and higher IL-6 levels were associated with shorter survival time in bivariate analysis. In multivariable analysis, SAP and higher IL-6 levels on day 1 were associated with shorter survival time. Conclusions SAP, lower mHLA-DR-expression and higher IL-6 levels on day one are associated with poor outcome and shorter survival time at 3 months after stroke onset. Trial registration www.clinicaltrials.gov, NCT01079728, March 3, 2010.
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Affiliation(s)
- A Mengel
- Department of Neurology Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany. .,Department of Neurology and Stroke, Universitätsklinik Tuebingen, Hoppe-Seyler-Str.3, 72076, Tuebingen, Germany.
| | - L Ulm
- Department of Neurology Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany.,Center for Clinical Research, The University of Queensland, Herston, Queensland, 4029, Australia
| | - B Hotter
- Department of Neurology Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany.,Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany
| | - H Harms
- Department of Neurology Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany
| | - S K Piper
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Charitéplatz 1, D-10117, Berlin, Germany.,Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany
| | - U Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Charitéplatz 1, D-10117, Berlin, Germany.,Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178, Berlin, Germany
| | - J Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institut de Recerca, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - C Meisel
- NeuroCure Clinical Research Center Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany
| | - A Meisel
- Department of Neurology Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany.,Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany.,NeuroCure Clinical Research Center Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany
| | - S Hoffmann
- Department of Neurology Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany.,NeuroCure Clinical Research Center Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10115, Berlin, Germany
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21
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Kishore AK, Jeans AR, Garau J, Bustamante A, Kalra L, Langhorne P, Chamorro A, Urra X, Katan M, Napoli MD, Westendorp W, Nederkoorn PJ, van de Beek D, Roffe C, Woodhead M, Montaner J, Meisel A, Smith CJ. Antibiotic treatment for pneumonia complicating stroke: Recommendations from the pneumonia in stroke consensus (PISCES) group. Eur Stroke J 2019; 4:318-328. [PMID: 31903430 DOI: 10.1177/2396987319851335] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/26/2019] [Indexed: 01/26/2023] Open
Abstract
Purpose The microbiological aetiology of pneumonia complicating stroke is poorly characterised. In this second Pneumonia in Stroke ConsEnsuS statement, we propose a standardised approach to empirical antibiotic therapy in pneumonia complicating stroke, based on likely microbiological aetiology, to improve antibiotic stewardship. Methods Systematic literature searches of multiple databases were undertaken. An evidence review and a round of consensus consultation were completed prior to a final multi-disciplinary consensus meeting in September 2017, held in Barcelona, Spain. Consensus was approached using a modified Delphi technique and defined a priori as 75% agreement between the consensus group members.Findings: No randomised trials to guide antibiotic treatment of pneumonia complicating stroke were identified. Consensus was reached for the following: (1) Stroke-associated pneumonia may be caused by organisms associated with either community-acquired or hospital-acquired pneumonia; (2) Treatment for early stroke-associated pneumonia (<72 h of stroke onset) should cover community-acquired pneumonia organisms; (3) Treatment for late stroke-associated pneumonia (≥72 h and within seven days of stroke onset) should cover community-acquired pneumonia organisms plus coliforms +/- Pseudomonas spp. if risk factors; (4) No additional antimicrobial cover is required for patients with dysphagia or aspiration; (5) Pneumonia occurring after seven days from stroke onset should be treated as for hospital-acquired pneumonia; (6) Treatment should continue for at least seven days for each of these scenarios. Discussion Consensus recommendations for antibiotic treatment of the spectrum of pneumonia complicating stroke are proposed. However, there was limited evidence available to formulate consensus on choice of specific antibiotic class for pneumonia complicating stroke. Conclusion Further studies are required to inform evidence-based treatment of stroke-associated pneumonia including randomised trials of antibiotics and validation of candidate biomarkers.
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Affiliation(s)
- Amit K Kishore
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Adam R Jeans
- Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK
| | - Javier Garau
- Department of Medicine, Hospital Universitari Mutua de Terrassa, Barcelona, Clinica Rotger Quironsalud, Palma of Mallorca, Spain
| | - Alejandro Bustamante
- Neurovascular Research Lab, Vall d'Hebron Research Institute, Barcelona, Spain, Spain
| | - Lalit Kalra
- Clinical Neurosciences, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Angel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Mira Katan
- Department of Neurology, Stroke Center, University Hospital of Zurich, Zurich, Switzerland
| | - Mario Di Napoli
- Stroke Unit, San Camillo de' Lellis General Hospital, Rieti, Italy
| | - Willeke Westendorp
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Meibergdreef, Amsterdam, Netherlands
| | - Paul J Nederkoorn
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Meibergdreef, Amsterdam, Netherlands
| | - Diederik van de Beek
- Amsterdam UMC, University of Amsterdam, Department of Neurology, Amsterdam Neuroscience, Meibergdreef, Amsterdam, Netherlands
| | - Christine Roffe
- Keele University Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Stoke-on-Trent, UK
| | - Mark Woodhead
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Joan Montaner
- Neurovascular Research Lab, Vall d'Hebron Research Institute, Barcelona, Spain, Spain.,Institute de Biomedicine of Seville, IBiS/Hospitales Universitarios Virgen del Rocío y Macarena, University of Seville, Seville, Spain
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Department of Neurology, Charité Universitaetsmedizin Berlin, Germany
| | - Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
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22
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Yang JL, Chen TL, Yeh CC, Hu CJ, Liao CC, Lane HL, Shih CC. Acupuncture treatment and the risk of urinary tract infection in stroke patients: a nationwide matched cohort study. Acupunct Med 2019; 37:175-183. [PMID: 31032620 DOI: 10.1177/0964528419834017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The association between acupuncture treatment and post-stroke urinary tract infection (UTI) remains incompletely understood. OBJECTIVE To compare the long-term risks of UTI among stroke patients treated with or without acupuncture treatment. METHODS This retrospective cohort study was based on data from the National Health Insurance Research Database in Taiwan that included hospitalized stroke patients. We identified 19,286 patients aged 30 years and older who were hospitalized for newly diagnosed stroke between 1 January 2000 and 31 December 2004. Considering immortal time bias, we compared the incidence of UTI during the follow-up period until the end of 2009 in patients with stroke who did and did not receive acupuncture. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of UTI associated with acupuncture were calculated using multivariate Cox proportional hazard regression analysis. RESULTS Stroke patients who received acupuncture treatment experienced a lower incidence of UTI than those who were not treated with acupuncture (95.4 vs 110.0 per 1000 person-years) with an HR of 0.76 (95% CI: 0.73-0.80). The association between acupuncture treatment and UTI was significant for both sexes and for patients older than 40 years of age, particularly for patients who had no history of medical conditions. CONCLUSIONS In this nationwide retrospective cohort study, we raised the possibility that acupuncture treatment may be associated with a reduced risk of UTI among stroke patients. However, the protective effect associated with acupuncture treatment requires further validation using randomized clinical trials.
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Affiliation(s)
- Jen-Lin Yang
- 1 Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,2 Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ta-Liang Chen
- 3 Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,4 Department of Anesthesiology, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Chieh Yeh
- 5 Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,6 Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Chaur-Jong Hu
- 7 Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chien-Chang Liao
- 4 Department of Anesthesiology, School of Medicine, Taipei Medical University, Taipei, Taiwan.,8 Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan.,9 Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan.,10 School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.,11 Department of Anesthesiology, Shuan Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsin-Long Lane
- 12 School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung, Taiwan
| | - Chun-Chuan Shih
- 12 School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung, Taiwan.,13 Ph.D. Program in Clinical Drug Development of Herbal Medicine, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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23
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Ramchand P, Thibault DP, Crispo JA, Levine J, Hurst R, Mullen MT, Kasner S, Willis AW. Readmissions After Mechanical Thrombectomy for Acute Ischemic Stroke in the United States: A Nationwide Analysis. J Stroke Cerebrovasc Dis 2018; 27:2632-2640. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 11/30/2022] Open
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24
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Vermeij JD, Westendorp WF, van de Beek D, Nederkoorn PJ. Post-stroke infections and preventive antibiotics in stroke: Update of clinical evidence. Int J Stroke 2018; 13:913-920. [PMID: 30175940 DOI: 10.1177/1747493018798557] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Jan-Dirk Vermeij
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Willeke F Westendorp
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
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25
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Dhamapurkar SK, Wilson BA, Rose A, Florschutz G, Watson P, Shiel A. Does a regular Wessex Head Injury Matrix assessment identify early signs of infections in people with Prolonged Disorders of Consciousness? Brain Inj 2018; 32:1103-1109. [PMID: 29894208 DOI: 10.1080/02699052.2018.1484165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND & OBJECTIVE Patients with brain injury are at high risk for infections. Although infection and cognitive deterioration are established for people with dementia, this has not been shown for patients with a prolonged disorder of consciousness (PDOC). This study determines whether regular Wessex Head Injury Matrix (WHIM) assessments can identify early signs of infections in patients with PDOC. METHOD Retrospective and prospective approaches were used to assess the WHIM scores of patients with a PDOC (N = 21 in the retrospective study and 22 in the prospective study). RESULTS The WHIM total scores decreased due to infections in 17 of the 21 cases of infection (p < 0.001) in the retrospective study and 15 (p = 0.001) of the 22 prospective cases of infection. Patients in a minimally conscious state (MCS) showed a bigger proportion of change between their baseline score and the scores taken in the pre-infection stage in both the retrospective and prospective studies when compared to patients in a vegetative state (VS). CONCLUSION The findings suggest the importance of serial WHIM assessments throughout the period of recovery, not only to measure cognitive changes but also to highlight underlying physical changes such as infections that will impact the response to rehabilitation and recovery.
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Affiliation(s)
- Samira Kashinath Dhamapurkar
- a OT Department , The Raphael Hospital , Kent , Tonbridge , UK.,d OT Department , The National University of Ireland , Ireland , Galway
| | - Barbara A Wilson
- a OT Department , The Raphael Hospital , Kent , Tonbridge , UK.,b Neuropsychology Department , Oliver Zangwill Centre , Cambridgeshire , Cambridge , UK
| | - Anita Rose
- a OT Department , The Raphael Hospital , Kent , Tonbridge , UK
| | | | - Peter Watson
- c MRC Cognition and Brain Sciences Unit , Cambridgeshire , Cambridge , UK
| | - Agnes Shiel
- d OT Department , The National University of Ireland , Ireland , Galway
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26
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Yan T, Liu C, Li Y, Xiao W, Li Y, Wang S. Prevalence and predictive factors of urinary tract infection among patients with stroke: A meta-analysis. Am J Infect Control 2018; 46:402-409. [PMID: 29153643 DOI: 10.1016/j.ajic.2017.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 10/01/2017] [Accepted: 10/01/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is thought to be a common complication of stroke and is regarded as a potential risk factor for poor stroke outcomes. However, there is a controversy among predictive factors of stroke-associated UTIs. We aim to estimate the prevalence and predisposing factors of UTIs among patients with stroke. METHODS PubMed, EMBASE, and Elsevier Science Direct were searched by 2 independent researchers. Sixteen studies with a total of 13,513 patients were included to evaluate the prevalence and predictive factors of stroke-associated UTIs published from the earliest records to March 10, 2017. Pooled effect sizes were calculated using the fixed effect model or random effect model according to I2 and P values. RESULTS The pooled prevalence of UTI was 19.0% (95% confidence interval [CI], 15%-22%; P <.01). The predisposing factors for UTIs include female sex (odds ratio [OR], 1.93; 95% CI, 1.55-2.41), older age (OR, 1.28; 95% CI, 1.09-1.50), higher modified Rankin Scale score (OR, 1.90; 95% CI, 1.43-2.53), and postvoid residual volume >100 mL (OR, 3.69; 95% CI, 2.09-6.52). CONCLUSIONS Approximately one-fifth of patients with stroke contracted at least 1 UTI after cerebral apoplexy. Female sex, older age, higher modified Rankin Scale score, and postvoid residual volume >100 mL were associated with higher risk of UTI.
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Affiliation(s)
- Tianyuan Yan
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, Shandong Province, China; School of Nursing, Shandong University, Jinan, Shandong Province, China
| | - Chenxia Liu
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, Shandong Province, China; School of Nursing, Shandong University, Jinan, Shandong Province, China
| | - Yingxia Li
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Wei Xiao
- Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Yating Li
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, Shandong Province, China; School of Nursing, Shandong University, Jinan, Shandong Province, China
| | - Shuhui Wang
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, Shandong Province, China.
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27
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Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015. J Stroke Cerebrovasc Dis 2018. [PMID: 29526387 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality. MATERIALS AND METHODS This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015. RESULTS Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections. CONCLUSIONS Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.
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28
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Vermeij J, Westendorp WF, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic therapy for preventing infections in people with acute stroke. Cochrane Database Syst Rev 2018; 1:CD008530. [PMID: 29355906 PMCID: PMC6491314 DOI: 10.1002/14651858.cd008530.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stroke is the main cause of disability in high-income countries and ranks second as a cause of death worldwide. Infections occur frequently after stroke and may adversely affect outcome. Preventive antibiotic therapy in the acute phase of stroke may reduce the incidence of infections and improve outcome. In the previous version of this Cochrane Review, published in 2012, we found that antibiotics did reduce the risk of infection but did not reduce the number of dependent or deceased patients. However, included studies were small and heterogeneous. In 2015, two large clinical trials were published, warranting an update of this Review. OBJECTIVES To assess the effectiveness and safety of preventive antibiotic therapy in people with ischaemic or haemorrhagic stroke. We wished to determine whether preventive antibiotic therapy in people with acute stroke:• reduces the risk of a poor functional outcome (dependency and/or death) at follow-up;• reduces the occurrence of infections in the acute phase of stroke;• reduces the occurrence of elevated body temperature (temperature ≥ 38° C) in the acute phase of stroke;• reduces length of hospital stay; or• leads to an increased rate of serious adverse events, such as anaphylactic shock, skin rash, or colonisation with antibiotic-resistant micro-organisms. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (25 June 2017); the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 5; 25 June 2017) in the Cochrane Library; MEDLINE Ovid (1950 to 11 May 2017), and Embase Ovid (1980 to 11 May 2017). In an effort to identify further published, unpublished, and ongoing trials, we searched trials and research registers, scanned reference lists, and contacted trial authors, colleagues, and researchers in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) of preventive antibiotic therapy versus control (placebo or open control) in people with acute ischaemic or haemorrhagic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected articles and extracted data; we discussed and resolved discrepancies at a consensus meeting with a third review author. We contacted study authors to obtain missing data when required. An independent review author assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated risk ratios (RRs) for dichotomous outcomes, assessed heterogeneity amongst included studies, and performed subgroup analyses on study quality. MAIN RESULTS We included eight studies involving 4488 participants. Regarding quality of evidence, trials showed differences in study population, study design, type of antibiotic, and definition of infection; however, primary outcomes among the included studies were consistent. Mortality rate in the preventive antibiotic group was not significantly different from that in the control group (373/2208 (17%) vs 360/2214 (16%); RR 1.03, 95% confidence interval (CI) 0.87 to 1.21; high-quality evidence). The number of participants with a poor functional outcome (death or dependency) in the preventive antibiotic therapy group was also not significantly different from that in the control group (1158/2168 (53%) vs 1182/2164 (55%); RR 0.99, 95% CI 0.89 to 1.10; moderate-quality evidence). However, preventive antibiotic therapy did significantly reduce the incidence of 'overall' infections in participants with acute stroke from 26% to 19% (408/2161 (19%) vs 558/2156 (26%); RR 0.71, 95% CI 0.58 to 0.88; high-quality evidence). This finding was highly significant for urinary tract infections (81/2131 (4%) vs 204/2126 (10%); RR 0.40, 95% CI 0.32 to 0.51; high-quality evidence), whereas no preventive effect for pneumonia was found (222/2131 (10%) vs 235/2126 (11%); RR 0.95, 95% CI 0.80 to 1.13; high-quality evidence). No major side effects of preventive antibiotic therapy were reported. Only two studies qualitatively assessed the occurrence of elevated body temperature; therefore, these results could not be pooled. Only one study reported length of hospital stay. AUTHORS' CONCLUSIONS Preventive antibiotics had no effect on functional outcome or mortality, but significantly reduced the risk of 'overall' infections. This reduction was driven mainly by prevention of urinary tract infection; no effect for pneumonia was found.
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Affiliation(s)
- Jan‐Dirk Vermeij
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Willeke F Westendorp
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Diederik WJ Dippel
- Erasmus MC University Medical CenterPO Box 2040RotterdamNetherlands3000 CA
| | - Diederik van de Beek
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
| | - Paul J Nederkoorn
- University of AmsterdamDepartment of Neurology, Academic Medical CentrePO Box 22660AmsterdamNetherlands1100 DD
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29
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Stroke-associated infection independently predicts 3-month poor functional outcome and mortality. J Neurol 2017; 265:370-375. [DOI: 10.1007/s00415-017-8714-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/13/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
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30
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Ruborg R, Gunnarsson K, Ström JO. Predictors of post-stroke body temperature elevation. BMC Neurol 2017; 17:218. [PMID: 29237408 PMCID: PMC5729487 DOI: 10.1186/s12883-017-1002-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/05/2017] [Indexed: 11/10/2022] Open
Abstract
Background Growing evidence indicates that elevated body temperature after stroke is associated with unfavorable outcome. The aim of the current study was to investigate which factors predict temperature elevation within 48 h of stroke onset. Specifically, we hypothesized that temperature elevation would be associated with stroke symptom severity and that hemorrhagic stroke would cause a more pronounced temperature increase compared to ischemic stroke. Methods The medical records of 400 stroke patients were retrospectively reviewed. Multiple linear regression analysis was used to determine which factors were associated with elevated body temperature. Results Several factors were significantly associated with peak body temperature (the highest recorded body temperature) within 48 h of stroke onset: stroke severity measured by the National Institutes of Health Stroke Scale (NIHSS) (regression coefficient; (RC) 0.022), female gender (RC 0.157), tympanic/non-rectal temperature reading (RC −0.265), swallowing difficulties (RC 0.335), intubation (RC 0.470), antipyretic treatment (RC 0.563), and C-reactive protein > 50 or signs of infection at admission (RC 0.298). Contrary to our expectations, patients with intracerebral hemorrhage did not have higher peak body temperatures than patients with ischemic stroke. Conclusions In conclusion, temperature elevation within the first 48 h of stroke onset is common, can be partially predicted using information at admission and is strongly associated with stroke severity. The strong association with stroke severity may, at least partly, explain the previously described association between post-stroke temperature elevation and unfavorable outcome.
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Affiliation(s)
- Rebecca Ruborg
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karin Gunnarsson
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jakob O Ström
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden. .,Region Örebro Län, Neuro- och rehabmedicinska kliniken, Södra Grev Rosengatan, 701 85, Örebro, Sweden.
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31
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Zheng F, von Spreckelsen N, Zhang X, Stavrinou P, Timmer M, Dohmen C, Goldbrunner R, Cao F, Zhang Q, Ran Q, Li G, Fan R, Yao S, Krischek B. Should preventive antibiotics be used in patients with acute stroke? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0186607. [PMID: 29049353 PMCID: PMC5648227 DOI: 10.1371/journal.pone.0186607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Infection is a common complication in acute stroke. Whether or not preventive antibiotics reduce the risk of infection or even lead to a favorable outcome and reduction of mortality after a stroke still remains equivocal. This review was performed to update the current knowledge on the effect and possible benefits of prophylactic antibiotic therapy in patients with stroke. METHODS A systematic review and meta-analysis of preventive antibiotics`effect on the incidence of infection, favorable outcome (mRS≤2) and mortality in patients with acute stroke is performed with relevant randomized controlled trials. RESULTS Six studies were identified, involving 4125 participants. Compared with the control group, the treated groups were significantly less prone to suffer from early overall infections [RR = 0.52, 95%CI (0.39, 0.70), p<0.0001], early pneumonia [RR = 0.64, 95%CI (0.42, 0.96), p = 0.03] and early urinary tract infections [RR = 0.35, 95%CI (0.25, 0.48), p<0.00001]. However, there was no significant difference in overall mortality [RR = 1.07, 95%CI (0.90, 1.27), p = 0.44], early mortality [RR = 0.99, 95%CI (0.78, 1.26), p = 0.92], late mortality [RR = 1.12, 95%CI (0.94, 1.35), p = 0.21] or favorable outcome [RR = 1.00, 95%CI (0.92, 1.08), p = 0.98]. CONCLUSION Although preventive antibiotic treatment did reduce the occurrence of early overall infections, early pneumonia and early urinary tract infection in patients with acute stroke, this advantage was not eventually translated to a favorable outcome and reduction in mortality. Future studies are warranted to identify any subgroup of stroke patients who might benefit from preventive antibiotic treatment.
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Affiliation(s)
- Feng Zheng
- Department of Neurosurgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
- * E-mail: (BK); (FZ)
| | | | - Xintong Zhang
- Department of Neurosurgery, The Second Clinical Medical School of Inner Mongolia University for the Nationalities (Inner Mongolia Forestry General Hospital), Inner Mongolia, China
| | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Fang Cao
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qishan Ran
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Ruiming Fan
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, the first affiliated hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
- * E-mail: (BK); (FZ)
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32
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Suda S, Aoki J, Shimoyama T, Suzuki K, Sakamoto Y, Katano T, Okubo S, Nito C, Nishiyama Y, Mishina M, Kimura K. Low Free Triiodothyronine at Admission Predicts Poststroke Infection. J Stroke Cerebrovasc Dis 2017; 27:397-403. [PMID: 29031498 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/11/2017] [Accepted: 09/11/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Poststroke infection (PSI) is common and is usually associated with a severe prognosis. We investigated the association between PSI and thyroid hormones, which are critical to immune regulation, in patients with acute stroke. METHODS We retrospectively enrolled 520 consecutive patients with acute ischemic stroke (326 men; age, 71.9 ± 13.2 years) admitted to our department between September 2014 and June 2016. The impact of serum thyroid hormone levels measured at admission (thyroid-stimulating hormone [TSH], free triiodothyronine [FT3], and free thyroxine [FT4]) on the PSI was evaluated using multivariate logistic regression analysis. RESULTS We diagnosed 107 patients (20.6%; pneumonia, 65; urinary tract infection, 19; others, 23) with PSIs. While age (P <.001), body mass index (P = .0012), preadmission modified Rankin scale score (P = .0001), National Institutes of Health Stroke Scale score on admission (P <.001), admission FT3 level (P <.001), atrial fibrillation (P <.001), and ischemic heart disease (P = .0451) were significantly associated with PSI, we found no relationship among TSH levels, FT4 levels, and PSI occurrence. After multivariate adjustment, patients with PSIs were more frequently in the Q1 quartile (≤2.25 pg/mL) than in the Q2 (2.26-2.55 pg/mL; P = .0251), Q3 (2.56-2.89 pg/mL; P = .0007), or Q4 (≥2.90 pg/mL; P = .0010) quartiles of FT3 levels. Moreover, low FT3 levels (<2.29 pg/mL) were independently associated with PSI occurrence (P = .0013). CONCLUSIONS Low FT3 levels at admission are independently associated with PSI occurrence.
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Affiliation(s)
- Satoshi Suda
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
| | - Junya Aoki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Takashi Shimoyama
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kentaro Suzuki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuki Sakamoto
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Takehiro Katano
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Seiji Okubo
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Chikako Nito
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yasuhiro Nishiyama
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Masahiro Mishina
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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Frost FS, Fan Y, Harrison A, Modlin T, Samuel S, Thompson N, Katzan I. Failed Removal of Indwelling Urinary Catheters in Patients With Acute Stroke: Incidence and Risk Factors. PM R 2017; 10:160-167. [PMID: 28694220 DOI: 10.1016/j.pmrj.2017.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 03/03/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Reducing the incidence of indwelling urinary catheter (IUC) use and early removal of the devices that are inserted are appropriate priorities for quality patient care. Just like symptomatic bacteriuria, failed catheter removal as a complication of IUC use is associated with considerable morbidity. In the ideal setting, patients who need IUCs have them, and patients who do not need them will have them removed safely, with the goal of reducing medical complications and facilitating the rehabilitation phase of care. OBJECTIVE To determine the incidence of failed removal of IUCs and the factors associated with failed removal in persons hospitalized with acute stroke. DESIGN Retrospective review of medical records and associated clinical data collection platforms. SETTING Comprehensive stroke center at a tertiary care hospital. PATIENTS The study cohort included 175 stroke patients admitted to the hospital and managed with IUCs. Mean age was 66.1 years (standard deviation = 15), 55% were female. METHODS Univariable and multiple logistic regression analyses were performed. Variables assessed included age, gender, race, duration of hospital stay, stroke subtype, National Institutes of Health Stroke Scale, and 6-Clicks Scale, which is a measure of functional status. MAIN OUTCOME MEASUREMENTS The dependent variable was occurrence of a failed attempt at removal of an IUC, defined as removal followed by a catheter reinsertion. RESULTS During the study period, 175 of 432 patients with acute hospital admission for new stroke had an IUC removal event. Of these patients, 46 (26%) experienced a failed catheter removal. On univariate analysis, factors significantly associated with failed removal included presence of a hemorrhagic stroke (P = .005), lower level of physical function (by 6-Clicks and NIHSS scores), hospital length of stay (P < .001), and discharge location (P = .005). Bedside bladder ultrasound testing by nursing staff was used more frequently in the group of patients who had unsuccessful IUC removals (95% confidence interval 4.56-21.67, P < .001). Length of stay (P < .001), white race (P = .001), and hemorrhagic stroke (P = .009) were associated independently with failed catheter removal after adjustment for other clinical variables. CONCLUSIONS This single-site study identified a high incidence of failed urinary catheter removal in patients with stroke, along with factors associated with failed removal. This is the first step in developing a predictive model that could reduce the incidence of this adverse event. Policies, penalties, and protocols designed to reduce catheter days must be sensitive to the special situations in which IUCs are medically necessary and equal consideration given to identifying the patients for which catheter removal poses a greater risk than continued catheter use. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Frederick S Frost
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
| | - Youran Fan
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
| | - Alexander Harrison
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
| | - Trey Modlin
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
| | - Susan Samuel
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
| | - Nicholas Thompson
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
| | - Irene Katzan
- Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, 9500 Euclid Ave Desk S31, Cleveland, OH 44195.,Cleveland Clinic Foundation, Neurological Institute Center for Outcomes Research, Cleveland, OH.,Cleveland Clinic Foundation, Physical Medicine and Rehabilitation, Cleveland, OH.,Cleveland Clinic Foundation, Neurology, Cleveland, OH
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Xi YG, Tian X, Chen WQ, Zhang S, Zhang S, Ren WD, Pang QJ, Yang GT, Yang ZM. Antibiotic prophylaxis for infections in patients with acute stroke: a systematic review and meta-analysis of randomized controlled trials. Oncotarget 2017; 8:81075-81087. [PMID: 29113368 PMCID: PMC5655263 DOI: 10.18632/oncotarget.19039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/17/2017] [Indexed: 12/18/2022] Open
Abstract
Objective Infections are frequent after stroke and lead to increased mortality and neurological disability. Antibiotic prophylaxis has potential of decreasing the risk of infections and mortality and improving poor functional outcome. Several studies evaluated antibiotic prophylaxis for infections in acute stroke patients have generated conflicting results. The systematic review of randomized clinical trials (RCTs) aimed at comprehensively assessing the evidence of antibiotic prophylaxis for the treatment of acute stroke patients. Materials and Methods PubMed, EMBASE, the Cochrane library and the reference lists of eligible articles were searched to identify all potential studies. We included the studies that investigated the efficacy and safety of antibiotic prophylaxis for the treatment of acute stroke patients. The primary outcome included mortality and infection rate. The secondary outcomes included poor functional outcome and adverse events. Results Seven trials randomizing 4,261 patients were included. Pooled analyses showed that antibiotic prophylaxis did not improve the mortality (risk ratio (RR) = 1.03, 95% confidence interval (CI) 0.84 to 1.26, p = 0.78, I2 = 25%) and poor functional outcome (RR = 0.93, 95% CI 0.80 to 1.08, p = 0.32, I2 = 80%), but reduced the incidence of infection (RR = 0.67, 95% CI 0.53 to 0.84, p = 0.0007, I2 = 49%). No major side effects were reported. Sensitivity analyses confirmed the results of infection rate and poor functional outcome. Conclusions Antibiotic prophylaxis can be used to treat the infectious events of acute stroke patients although it has no potential of decreased mortality and improved functional outcome.
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Affiliation(s)
- Yan-Guo Xi
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Xu Tian
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Wei-Qing Chen
- Department of Gastroenterology, Chongqing Cancer Institute and Hospital and Cancer Center, Chongqing 400030, China
| | - Sai Zhang
- Department of Neurosurgery, Logistic University Affiliated Hospital, Logistic University of Chinese People's Armed Police Force, Tianjin 300162, China
| | - Shan Zhang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Wei-Dan Ren
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Qi-Jun Pang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Guo-Tao Yang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
| | - Zhi-Ming Yang
- Department of Neurosurgery, Cang Zhou Central Hospital, Hebei 061001, China
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The Efficacy of Prophylactic Antibiotics on Post-Stroke Infections: An Updated Systematic Review and Meta-Analysis. Sci Rep 2016; 6:36656. [PMID: 27841284 PMCID: PMC5107889 DOI: 10.1038/srep36656] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/18/2016] [Indexed: 11/21/2022] Open
Abstract
Post-stroke infections are common complications in acute stroke patients and are associated with an unfavorable functional outcome. However, reports on the effects of prophylactic antibiotics treatment on post-stroke infections are conflicting, especially those on post-stroke pneumonia and outcomes. We searched the PubMed, Embase, and Web of Knowledge databases up through March 11th, 2016. Seven randomized controlled trials including 4261 patients were analyzed among this systematic review and meta-analysis. We found preventive antibiotics treatment at the time of stroke onset did reduce the incidence of infections in adults with acute stroke (OR = 0.57, 95% CI: 0.38–0.85, P = 0.005), including reducing the number of urinary tract infections (OR = 0.34, 95% CI: 0.26–0.46, P < 0.001), but did not significantly decrease the rate of post-stroke pneumonia (OR = 0.91, 95% CI: 0.73–1.13, P = 0.385). Importantly, antibiotics treatment also showed no significant effect on the number of fatalities among stroke patients (OR = 1.07, 95% CI: 0.90–1.26, P = 0.743) and functional outcome scores on the modified Rankin Scale (OR = 1.76, 95% CI: 0.86–3.63, p = 0.124). Our study indicated that preventive antibiotics treatment not reduced the rate of post-stroke pneumonia or mortality, even though decreased the risk of infections, especially urinary tract infections. Thus, preventive antibiotics treatment may not be recommended for acute stroke patients.
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Stefanovic Budimkic M, Pekmezovic T, Beslac-Bumbasirevic L, Ercegovac M, Berisavac I, Stanarcevic P, Padjen V, Jovanović DR. Long-Term Prognosis in Ischemic Stroke Patients Treated with Intravenous Thrombolytic Therapy. J Stroke Cerebrovasc Dis 2016; 26:196-203. [PMID: 28341074 DOI: 10.1016/j.jstrokecerebrovasdis.2016.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 08/30/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND AND PURPOSE It remains unclear if intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator has an impact on the survival and maintenance of a favorable effect on functional recovery over a long follow-up period. The aim of this study was to assess whether or not IVT treatment has a favorable effect on functional recovery and survival less than 1 year after a stroke. METHODS This matched cohort study included 259 patients with acute ischemic stroke (IS) who were treated with IVT and standard care and 259 patients treated with standard care alone in the stroke unit between February 2006 and January 2013. RESULTS After a median follow-up period of 3 years (range, 1-7 years), survival did not differ significantly between the groups; specifically, 56 patients (21.6%) in the thrombolysed group died versus 62 patients (23.94%) in the nonthrombolysed group (log-rank, .240, P = .624). Based on a multivariate Cox proportional hazards regression model, older age (>70 years), stroke severity (National Institutes of Health Stroke Scale score ≥ 15), diabetes mellitus, and a history of atrial fibrillation were independent predictors of long-term mortality after stroke. After the follow-up period, 144 patients (55.6%) in the IVT-treated group versus 112 patients (43.2%) in the control group had an excellent outcome, with a modified Rankin Scale score of 0-1 (hazard ratio [HR] = 1.64, 95% confidence interval [CI] = 1.16-2.32). Based on a multivariate Cox proportional hazards regression model, an excellent 3-month functional recovery was a strong predictor of favorable outcome (HR = 11.27, 95% CI = 6.45-19.63). CONCLUSION The results suggest that IVT for acute IS has a favorable effect on functional recovery more than 1 year after stroke.
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Affiliation(s)
| | - Tatjana Pekmezovic
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty University of Belgrade, Belgrade, Serbia; Institute of Epidemiology, Belgrade, Serbia
| | - Ljiljana Beslac-Bumbasirevic
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Marko Ercegovac
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Ivana Berisavac
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty University of Belgrade, Belgrade, Serbia
| | | | - Visnja Padjen
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Dejana R Jovanović
- Neurology Clinic, Clinical Center of Serbia, Belgrade, Serbia; Medical Faculty University of Belgrade, Belgrade, Serbia.
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Westendorp WF, Vermeij JD, Brouwer MC, Roos YBWEM, Nederkoorn PJ, van de Beek D. Pre-Stroke Use of Beta-Blockers Does Not Lower Post-Stroke Infection Rate: An Exploratory Analysis of the Preventive Antibiotics in Stroke Study. Cerebrovasc Dis 2016; 42:506-511. [PMID: 27701170 DOI: 10.1159/000450926] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/15/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Stroke-associated infections occur frequently and are associated with unfavorable outcome. Previous cohort studies suggest a protective effect of beta-blockers (BBs) against infections. A sympathetic drive may increase immune suppression and infections. AIM This study is aimed at investigating the association between BB treatment at baseline and post-stroke infection in the Preventive Antibiotics in Stroke Study (PASS), a prospective clinical trial. METHODS We performed an exploratory analysis in PASS, 2,538 patients with acute phase of stroke (24 h after onset) were randomized to ceftriaxone (intravenous, 2 g per day for 4 days) in addition to stroke unit care, or standard stroke unit care without preventive antibiotic treatment. All clinical data, including use of BBs, was prospectively collected. Infection was diagnosed by the treating physician, and independently by an expert panel blinded for all other data. Multivariable analysis was performed to investigate the relation between BB treatment and infection rate. RESULTS Infection, as defined by the physician, occurred in 348 of 2,538 patients (14%). Multivariable analysis showed that the use of BBs at baseline was associated with the development of infection during clinical course (adjusted OR (aOR) 1.61, 95% CI 1.19-2.18; p < 0.01). BB use at baseline was also associated with the development of pneumonia (aOR 1.56, 95% CI 1.05-2.30; p = 0.03). Baseline BB use was not associated with mortality (aOR 1.14, 95% CI 0.84-1.53; p = 0.41) or unfavorable outcome at 3 months (aOR 1.10, 95% CI 0.89-1.35; p = 0.39). CONCLUSIONS Patients treated with BBs prior to stroke have a higher rate of infection and pneumonia.
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Affiliation(s)
- Willeke F Westendorp
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Colbert JF, Traystman RJ, Poisson SN, Herson PS, Ginde AA. Sex-Related Differences in the Risk of Hospital-Acquired Sepsis and Pneumonia Post Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2016; 25:2399-404. [PMID: 27363622 DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 06/03/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Infectious complications after ischemic stroke are frequent and lead to neurological deterioration, poor functional outcomes, and higher mortality. Local and systemic inflammatory responses to brain ischemia differ between males and females, but little is known about differences in poststroke susceptibility to infection by sex. The purpose of this study was to compare sex-related differences in the risk of hospital-acquired sepsis and pneumonia after acute ischemic stroke (AIS). MATERIALS AND METHODS This is a retrospective, secondary analysis of the 2010-2011 California State Inpatient Database. Previously validated International Classification of Disease, Ninth Revision (ICD-9) codes were used to identify adult hospitalizations for AIS. The primary outcome was hospital-acquired sepsis or pneumonia, also identified using ICD-9 codes. Associations between sex and hospital-acquired sepsis or pneumonia were adjusted for baseline characteristics and comorbidities using multivariable logistic regression. RESULTS There were 91,643 hospitalizations for AIS included in this analysis, of which 1027 had hospital-acquired sepsis and 1225 had hospital-acquired pneumonia. The in-hospital mortality without infection was 4.6%; the presence of hospital-acquired infections was associated with higher mortality for sepsis (32.7%) and pneumonia (21.9%). Female (versus male) sex was associated with lower adjusted odds of hospital-acquired sepsis (odds ratio [OR] .74, 95% confidence interval [CI] .65-.84) and pneumonia (OR .69, 95% CI .62-.78). This difference was similar across age strata. Among hospitalizations with either hospital-acquired sepsis or pneumonia, sex did not influence mortality. CONCLUSIONS Female sex was associated with a lower risk of hospital-acquired sepsis and pneumonia after AIS. Further investigation is needed to determine the mechanisms underlying this clinical observation.
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Affiliation(s)
| | | | | | - Paco S Herson
- University of Colorado School of Medicine, Aurora, CO
| | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, CO.
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Kishore AK, Vail A, Chamorro A, Garau J, Hopkins SJ, Di Napoli M, Kalra L, Langhorne P, Montaner J, Roffe C, Rudd AG, Tyrrell PJ, van de Beek D, Woodhead M, Meisel A, Smith CJ. How Is Pneumonia Diagnosed in Clinical Stroke Research? Stroke 2015; 46:1202-9. [DOI: 10.1161/strokeaha.114.007843] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/06/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Diagnosis of pneumonia complicating stroke is challenging, and there are currently no consensus diagnostic criteria. As a first step in developing such consensus-based diagnostic criteria, we undertook a systematic review to identify the existing diagnostic approaches to pneumonia in recent clinical stroke research to establish the variation in diagnosis and terminology.
Methods—
Studies of ischemic stroke, intracerebral hemorrhage, or both, which reported occurrence of pneumonia from January 2009 to March 2014, were considered and independently screened for inclusion by 2 reviewers after multiple searches using electronic databases. The primary analysis was to identify existing diagnostic approaches for pneumonia. Secondary analyses explored potential reasons for any heterogeneity where standard criteria for pneumonia had been applied.
Results—
Sixty-four studies (56% ischemic stroke, 6% intracerebral hemorrhage, 38% both) of 639 953 patients were included. Six studies (9%) reported no information on the diagnostic approach, whereas 12 (19%) used unspecified clinician-reported diagnosis or initiation of antibiotics. The majority used objective diagnostic criteria: 20 studies (31%) used respiratory or other published standard criteria; 26 studies (41%) used previously unpublished ad hoc criteria. The overall occurrence of pneumonia was 14.3% (95% confidence interval 13.2%–15.4%;
I
2
=98.9%). Occurrence was highest in studies applying standard criteria (19.1%; 95% confidence interval 15.1%–23.4%;
I
2
=98.5%). The substantial heterogeneity observed was not explained by stratifying for other potential confounders.
Conclusions—
We found considerable variation in terminology and the diagnostic approach to pneumonia. Our review supports the need for consensus development of operational diagnostic criteria for pneumonia complicating stroke.
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Affiliation(s)
- Amit K. Kishore
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Andy Vail
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Angel Chamorro
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Javier Garau
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Stephen J. Hopkins
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Mario Di Napoli
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Lalit Kalra
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Peter Langhorne
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Joan Montaner
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Christine Roffe
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Anthony G. Rudd
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Pippa J. Tyrrell
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Diederik van de Beek
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Mark Woodhead
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Andreas Meisel
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
| | - Craig J. Smith
- From the Stroke and Vascular Research Centre, University of Manchester, Institute of Cardiovascular Sciences, Greater Manchester Comprehensive Stroke Centre–Salford Royal Foundation Trust, UK (A.K.K., S.J.H., P.J.T., C.J.S.); Centre for Biostatistics, University of Manchester, Salford Royal Foundation Trust, UK (A.V.); Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de
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Westendorp WF, Vermeij JD, Zock E, Hooijenga IJ, Kruyt ND, Bosboom HJLW, Kwa VIH, Weisfelt M, Remmers MJM, ten Houten R, Schreuder AHCMT, Vermeer SE, van Dijk EJ, Dippel DWJ, Dijkgraaf MGW, Spanjaard L, Vermeulen M, van der Poll T, Prins JM, Vermeij FH, Roos YBWEM, Kleyweg RP, Kerkhoff H, Brouwer MC, Zwinderman AH, van de Beek D, Nederkoorn PJ. The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial. Lancet 2015; 385:1519-26. [PMID: 25612858 DOI: 10.1016/s0140-6736(14)62456-9] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In adults with acute stroke, infections occur commonly and are associated with an unfavourable functional outcome. In the Preventive Antibiotics in Stroke Study (PASS) we aimed to establish whether or not preventive antimicrobial therapy with a third-generation cephalosporin, ceftriaxone, improves functional outcome in patients with acute stroke. METHODS In this multicentre, randomised, open-label trial with masked endpoint assessment, patients with acute stroke were randomly assigned to intravenous ceftriaxone at a dose of 2 g, given every 24 h intravenously for 4 days, in addition to stroke unit care, or standard stroke unit care without preventive antimicrobial therapy; assignments were made within 24 h after symptom onset. The primary endpoint was functional outcome at 3 months, defined according to the modified Rankin Scale and analysed by intention to treat. The primary analysis was by ordinal regression of the primary outcome. Secondary outcomes included death, infection rates, antimicrobial use, and length of hospital stay. Participants and caregivers were aware of treatment allocation but assessors of outcome were masked to group assignment. This trial is registered with controlled-trials.com, number ISRCTN66140176. FINDINGS Between July 6, 2010, and March 23, 2014, a total of 2550 patients from 30 sites in the Netherlands, including academic and non-academic medical centres, were randomly assigned to the two treatment groups: 1275 patients to ceftriaxone and 1275 patients to standard treatment (control group). 12 patients (seven in the ceftriaxone group and five in the control group) withdrew consent immediately after randomisation, leaving 2538 patients available for the intention-to-treat-analysis (1268 in the ceftriaxone group and 1270 in the control group). 2514 (99%) of 2538 patients (1257 in each group) completed 3-month follow-up. Preventive ceftriaxone did not affect the distribution of functional outcome scores on the modified Rankin Scale at 3 months (adjusted common odds ratio 0·95 [95% CI 0·82-1·09], p=0·46). Preventive ceftriaxone did not result in an increased occurrence of adverse events. Overgrowth infection with Clostridium difficile occurred in two patients (<1%) in the ceftriaxone group and none in the control group. INTERPRETATION Preventive ceftriaxone does not improve functional outcome at 3 months in adults with acute stroke. The results of our trial do not support the use of preventive antibiotics in adults with acute stroke. FUNDING Netherlands Organization for Health Research and Development, Netherlands Heart Foundation, and the European Research Council.
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Affiliation(s)
- Willeke F Westendorp
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan-Dirk Vermeij
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Elles Zock
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Imke J Hooijenga
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Slotervaart Hospital, Amsterdam, Netherlands
| | - Hans J L W Bosboom
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Vincent I H Kwa
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Martijn Weisfelt
- Department of Neurology, Kennemer Gasthuis, Haarlem, Netherlands
| | | | - Robert ten Houten
- Department of Neurology, Medisch Centrum Alkmaar, Alkmaar, Netherlands
| | | | - Sarah E Vermeer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | - Ewout J van Dijk
- Department of Neurology, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Marcel G W Dijkgraaf
- Clinical Research Unit, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Lodewijk Spanjaard
- Department of Medical Microbiology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marinus Vermeulen
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Tom van der Poll
- Infectious Diseases, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jan M Prins
- Infectious Diseases, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Yvo B W E M Roos
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Ruud P Kleyweg
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
| | - Paul J Nederkoorn
- Department of Neurology, Centre of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Consoli D, Vidale S, Aguglia U, Bassi P, Cavallini A, Consoli A, Galati F, Guidetti D, Micieli G, Neri G, Rasura M, Sterzi R, Toni D, Inzitari D. The influence of previous infections and antichlamydia pneumoniae seropositivity on functional outcome in ischemic stroke patients: results from the IN2 study. J Neurol 2015; 262:1310-6. [PMID: 25808504 DOI: 10.1007/s00415-015-7712-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/10/2015] [Accepted: 03/11/2015] [Indexed: 11/26/2022]
Abstract
Although a growing attention is being paid to acute ischemic stroke patients, the correlation between clinical outcome and infectious events in this population has been poorly investigated. 749 ischemic stroke (mean age 71 years old, males 56%) patients were enrolled in this prospective case-control study by 11 Italian Stroke Units. Demographic data, vascular risk factors, previous infections and post-stroke infections (PSIs) were recorded. Blood samples were collected and the enzyme-linked immunoassay was chosen to measure Chlamydia pneumoniae IgG and IgA plasma antibodies (antibody titers were classified with specific cut-off levels: IgA > 1:16 and IgG > 1:64). Early poor outcome was defined as mRS score >2 at discharge, while poor outcome at 6-month follow-up. Univariate and multivariate analyses were performed. Median NIHSS was 7, IgA and IgG antichlamydia pneumoniae seropositivities were observed in 308 (37.1%) and 207 (23.6%) patients, respectively. Multivariate analyses showed significant correlations between PSIs and NIHSS (RR: 1.06; 95% CI 1.02-1.09; p < 0.001) and PSIs and IgA antichlamydia pneumoniae seropositivity (RR: 3.84; 95% CI 2.53-5.84; p < 0.001). Significant disability was associated with baseline NIHSS (RR: 1.32; 95% CI 1.16-1.50; p < 0.001), IgA (RR: 2.67; 95% CI 1.06-6.70; p = 0.035) and IgG antichlamydia (RR: 5.75; 95% CI 1.83-18.03; p = 0.003) seropositivity and atrial fibrillation (RR: 2.58; 95% CI 1.81-3.67; p < 0.001). While previous infections were not associated with functional outcome, antichlamydia antibodies play a negative role in ischemic stroke patients. Preventive strategies may reduce the stroke burden and improve the clinical outcome.
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Affiliation(s)
- Domenico Consoli
- Department of Neurology, "G. Jazzolino" Hospital, Via P. Fleming, 89900, Vibo Valentia, Italy,
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Stroke and urosepsis after discontinuation of rivaroxaban. Int J Cardiol 2013; 169:e77-8. [DOI: 10.1016/j.ijcard.2013.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 07/27/2013] [Accepted: 08/03/2013] [Indexed: 11/17/2022]
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