Examination of selected clinical factors and medication use as risk factors for pneumonia during stroke rehabilitation: a case-control study

Implications for respiratory muscle training in patients with stroke-associated pneumonia: a meta-analysis

PURPOSE

To evaluate the effect of respiratory muscle training on improving lung function in patients with stroke-associated pneumonia.

MATERIALS AND METHODS

A systematic retrieval was conducted using the databases of the Cochrane Library, PubMed, the Web of Science, Embase, ProQuest, and others. Studies involving patients who received respiratory muscle training with/without a breathing trainer and those who adopted routine post-stroke rehabilitation training were included in the systematic review. The statistical analysis was performed using RevMan 5.3 software.

RESULTS

Fourteen studies were included involving 850 patients with stroke. According to the results of the meta-analysis, compared with the control group, there were statistically significant differences in forced vital capacity (FVC) measurements (mean difference (MD) = 0.93, p < 0.0001) and improvement values for FEV1/FVC (MD = 0.65, p < 0.00001) in the experimental group. The FEV1 value was higher in the experimental group than in the control group (MD = 5.89, p < 0.0001). Furthermore, respiratory muscle training was superior to routine rehabilitation training for improving the PImax of patients with stroke (MD = 9.20, p < 0.0001). The patients had better respiratory tolerance after respiratory muscle training intervention (MD = 73.40, p < 0.0001).

CONCLUSIONS

The implementation of respiratory muscle training can improve FVC and FEV lung function indicators, inspiratory muscle strength and the 6-min walk test results in patients with stroke.

On the potential of drug repurposing in dysphagia treatment: New insights from a real-world pharmacovigilance study and a systematic review

Background: Polypharmacy is common in patients with dysphagia. Routinely used drugs may influence swallowing function either improving or worsening it. We aimed to explore the potential effects of three commonly used drug classes on dysphagia and aspiration pneumonia through a systematic review and a real-world data analysis to probe the possibility of drug repurposing for dysphagia treatment. Material and Methods: Five electronic databases were searched. Studies on adults at risk for dysphagia, treated with Dipeptidyl-Peptidase IV Inhibitors (DPP-4i), Adrenergic Beta-Antagonists (beta-blockers), or Angiotensin-Converting Enzyme Inhibitors (ACEi), and reporting outcomes on dysphagia or aspiration pneumonia were included. A nested case/non-case study was performed on adverse events recorded in the FDA Adverse Event Reporting System (FAERS) on patients >64 years. Cases (dysphagia or aspiration pneumonia) were compared between patients only treated with Levodopa and patients who were concomitantly treated with the drugs of interest. Results: Twenty studies were included in the review (17 on ACEi, 2 on beta-blockers, and 1 on DPP-4i). Contrasting findings on the effects of ACEi were found, with a protective effect mainly reported in Asian studies on neurological patients. Beta-blockers were associated with a reduced dysphagia rate. The study on DPP-4i suggested no effect on dysphagia and an increased risk of aspiration pneumonia. The FAERS analysis showed a reduction of the risk for dysphagia/aspiration pneumonia with ACEi, beta-blockers, and DPP-4i. Conclusion: Our study explores the potential drug repurposing of ACEi, beta-blockers and DPP-4i in neurological patients with dysphagia to improve swallowing function and reduce aspiration pneumonia risk. Future randomized controlled studies should confirm these results and clarify the underlying mechanisms of action.

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

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

Association between angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and community-acquired pneumonia: A nationwide population propensity-score matching study

BACKGROUND

Few large-scale cohort studies have investigated the association between community-acquired pneumonia and the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs). We aimed to study whether using ACEIs or ARBs had protective effects for community-acquired pneumonia.

METHODS

This database cohort study was conducted retrospectively in Taiwan. The hypertensive patients were the target population of this study. Patients with ARB use were defined as our first study cohort. The second study cohort comprised patients who used ACEI. Propensity-score matching at 1:1 was used between ARB users and non-ARB users. We recruited 67 944 participants for the ARB study and 58 062 participants for the ACEI study. The same matching was also performed between ACEI users and non-ACEI users. Cox proportional hazard regression was used to analyse the risk of the outcome of viral pneumonia.

RESULTS

The hazard ratio of community-acquired pneumonia for ARB users relative to non-ARB users was 0.33. The hazard ratio of community-acquired pneumonia was 0.71 times in ACEI users compared with ACEI nonusers. In stratification analysis, both ARB and ACEI both exhibited a protective effect for community-acquired pneumonia in each age and sex group. In the analysis of the effects of therapy duration, patients using ARB for fewer than 100 days exhibited a greater reduction in the risk of community-acquired pneumonia (adjusted HR = 0.58) compared with the non-ARB cohort. For the ACEI study, patients who used ACEI for 121-450 days were more likely to exhibit reduced risks of community-acquired pneumonia (adjusted HR = 0.5).

CONCLUSION

Both ACEI and ARB uses were associated with decreased risk of community-acquired pneumonia infection.

Comparison of infection risks and clinical outcomes in patients with and without SARS-CoV-2 lung infection under renin-angiotensin-aldosterone system blockade: Systematic review and meta-analysis

AIMS

Angiotensin-converting enzyme-2 (ACE2) is the receptor for SARS-CoV-2. Animal studies suggest that renin-angiotensin-aldosterone system (RAAS) blockers might increase the expression of ACE2 and potentially increase the risk of SARS-CoV-2 infection.

METHODS AND RESULTS

The effect of ACE inhibitor (ACEI) treatment on the pneumonia incidence in non-COVID-19 patients (25 studies, 330 780 patients) was associated with a 26% reduction of pneumonia risk (odds ratio [OR]: 0.74, P < .001). Pneumonia-related death cases in ACEI-treated non-COVID-19 patients were reduced by 27% (OR: 0.73, P = .004). However, angiotensin II receptor blockers (ARB) treatment (10 studies, 275 621 non-COVID-19 patients) did not alter pneumonia risk in patients. Pneumonia-related death cases in ARB-treated non-COVID-19 patients was analysed only in 1 study and was significantly reduced (OR, 0.47; 95% confidence interval, 0.30 to 0.72). Results from 11 studies (8.4 million patients) showed that the risk of getting infected with the SARS-CoV-2 virus was reduced by 13% (OR: 0.87, P = .014) in patients treated with ACEI, whereas analysis from 10 studies (8.4 million patients) treated with ARBs showed no effect (OR, 0.92, P = .354). Results from 34 studies in 67 644 COVID-19 patients showed that RAAS blockade reduces all-cause mortality by 24% (OR = 0.76, P = .04).

CONCLUSION

ACEIs reduce the risk of getting infected with the SARS-CoV-2 virus. Blocking the RAAS may decrease all-cause mortality in COVID-19 patients. ACEIs also reduce the risk of non-COVID pneumonia. All-cause mortality due to non-COVID pneumonia is reduced by ACEI and potentially by ARBs.

Antihypertensive drugs are associated with reduced fatal outcomes and improved clinical characteristics in elderly COVID-19 patients

The novel coronavirus (CoV) severe acute respiratory syndrome (SARS)-CoV-2 outbreak began at the end of 2019 in Wuhan, China, and has spread to over 200 countries. In this multicenter retrospective study, we identified 2190 adult patients admitted for laboratory-confirmed COVID-19 in three participating centers. Multivariate logistic regression was conducted in patients with comorbid hypertension to examine the potential association between clinical outcomes, disease severity, and clinical characteristics with the use of ACEI, ARB, calcium-channel blockers (CCB), beta-blockers (BB), and thiazide diuretics. The clinical outcome, dyspnea, and fatigue were significantly improved in patients, especially elderly patients who were older than 65 years, who took ARB drugs prior to hospitalization compared to patients who took no drugs. The reduction of disease severity of elderly COVID-19 patients was associated with CCB and ACEI users. Clinical indices, including CRP, lymphocyte count, procalcitonin D dimer, and hemoglobin, were significantly improved in elderly ARB users. In addition, the clinical outcomes were statistically significantly improved in patients who took antihypertension drugs ARB, BB, and CCB after statistical adjustment by all ages, gender, baseline of blood pressures, and coexisting medical conditions. Our data indicate that hypertension drugs ARB, ACEI, CCB, and BB might be beneficial for COVID-19 patients.

Association of Proton Pump Inhibitors With Hospitalization Risk in Children With Oropharyngeal Dysphagia

Importance

Proton pump inhibitors (PPI) are commonly prescribed to children with oropharyngeal dysphagia and resultant aspiration based on the assumption that these patients are at greater risk for reflux-related lung disease. There is little data to support this approach and the potential risk for increased infections in children treated with PPI may outweigh any potential benefit.

Objective

The aim of this study was to determine if there is an association between hospitalization risk in pediatric patients with oropharyngeal dysphagia and treatment with PPI.

Design, Setting, and Participants

We performed a retrospective cohort study to compare the frequency and length of hospitalizations for children who had abnormal results on videofluoroscopic swallow studies that were performed between January 1, 2015, and December 31, 2015, and who were or were not treated with PPI, with follow-up through December 31, 2016. Records were reviewed for children who presented for care at Boston Children's Hospital, a tertiary referral center. Participants included 293 children 2 years and younger with evidence of aspiration or penetration on videofluoroscopic swallow study.

Exposures

Groups were compared based on their exposure to PPI treatment.

Main Outcomes and Measures

The primary outcomes were hospital admission rate and hospital admission nights and these were measured as incident rates. Multivariable analyses were performed to determine predictors of hospitalization risk after adjusting for comorbidities. Kaplan-Meier curves were created to determine the association of PPI prescribing with time until first hospitalization.

Results

A total of 293 patients with a mean (SD) age of 8.8 (0.4) months and a mean (SD) follow-up time of 18.15 (0.20) months were included in the analysis. Patients treated with PPI had higher admission rates (Incidence rate ratio [IRR], 1.77; 95% CI, 1.16-2.68) and admission nights (IRR, 2.51; 95% CI, 1.36-4.62) even after adjustment for comorbidities. Patients with enteral tubes who were prescribed PPIs were at the highest risk for admission (hazard ratio [HR], 2.31; 95% CI, 1.24-4.31).

Conclusions and Relevance

Children with aspiration who are treated with PPI have increased risk of hospitalization compared with untreated patients. These results support growing concern about the risks of PPI use in children.

Healthcare-Associated Infections in the Neurocritical Care Unit

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Predictors of post-stroke fever and infections: a systematic review and meta-analysis

Background

Fever after stroke is common, and often caused by infections. In the current study, we aimed to test the hypothesis that pneumonia, urinary tract infection and all-cause fever (thought to include at least some proportion of endogenous fever) have different predicting factors, since they differ regarding etiology.

Methods

PubMed was searched systematically for articles describing predictors for post-stroke pneumonia, urinary tract infection and all-cause fever. A total of 5294 articles were manually assessed; first by title, then by abstract and finally by full text. Data was extracted from each study, and for variables reported in 3 or more articles, a meta-analysis was performed using a random effects model.

Results

Fifty-nine articles met the inclusion criteria. It was found that post-stroke pneumonia is predicted by age OR 1.07 (1.04–1.11), male sex OR 1.42 (1.17–1.74), National Institutes of Health Stroke Scale (NIHSS) OR 1.07 (1.05–1.09), dysphagia OR 3.53 (2.69–4.64), nasogastric tube OR 5.29 (3.01–9.32), diabetes OR 1.15 (1.08–1.23), mechanical ventilation OR 4.65 (2.50–8.65), smoking OR 1.16 (1.08–1.26), Chronic Obstructive Pulmonary Disease (COPD) OR 4.48 (1.82–11.00) and atrial fibrillation OR 1.37 (1.22–1.55). An opposite relation to sex may exist for UTI, which seems to be more common in women.

Conclusions

The lack of studies simultaneously studying a wide range of predictors for UTI or all-cause fever calls for future research in this area. The importance of new research would be to improve our understanding of fever complications to facilitate greater vigilance, monitoring, prevention, diagnosis and treatment.

Effects of aspiration pneumonia on the intensive care requirements and in-hospital mortality of hospitalised patients with acute cerebrovascular disease

INTRODUCTION

In this study, we aimed to evaluate the effects of the development of aspiration pneumonia (AP) on the intensive care unit (ICU) requirements and in-hospital mortality of patients hospitalised in the neurology ward due to an acute cerebrovascular accident (CVA).

MATERIAL AND METHODS

Five hundred and three patients hospitalised in the neurology ward following an acute CVA were retrospectively analysed. The patients were divided into two groups: those with AP (group 1) and those without AP (group 2). Demographic characteristics and physical and radiological findings, including the localisation, lateralisation and aetiology of the infarction, in addition to ICU requirements and mortality, were evaluated.

RESULTS

Aspiration pneumonia was detected in 80 (15.9%) patients during the in-hospital stay. Transfer to the ICU for any reason was required in 37.5% of the patients in group 1 and 4.7% of those in group 2 (p < 0.001). In-hospital mortality occurred in 7.5% and 1.4% of the patients in group 1 and group 2, respectively (p = 0.006). The incidence of AP was highest in patients with an infarction of the medial cerebral artery (MCA) (p < 0.001). The AP was associated with older age (p < 0.001), hypertension (p = 0.007), echocardiography findings (p = 0.032) and the modified Rankin Scale (mRS) score (p < 0.001).

CONCLUSIONS

Our findings suggest that the requirement rate for transfer to the ICU and the mortality rate appear to be significantly higher in patients with a diagnosis of AP. Precautions should be taken, starting from the first day of hospitalisation, to decrease the incidence of AP in patients with acute CVA, focusing especially on older patients and those with a severe mRS score.

[Risk factors for the onset of aspiration pneumonia among stroke patients in the recovery stage]

AIM

Post-stroke aspiration pneumonia is one of the most common complications among stroke patients. Although the onset of aspiration pneumonia is caused by a disruption of the balance between invasion (the type and amount of oral flora and aspiration) and host resistance (the protective airway reflex and immune function), several previous studies have focused on invasion, such as aspiration and dysphagia. In this study, we examined the importance of the host resistance to aspiration pneumonia among stroke patients with dysphagia.

METHODS

The study subjects included 76 stroke patients (mean age, 74.7±8.4 years) with dysphagia chosen from 175 stroke patients who were newly admitted to four rehabilitation hospitals. We divided the subjects into two groups based on the onset of pneumonia during the period of admission and compared their status.

RESULTS

Ten patients (13.2%) developed pneumonia at the hospital, and all of the affected patients were over 65 years old. Significant differences existed between the two groups with respect to the gender, activity level, albumin level, nutrition method and severity of dysphagia (p<0.05).

CONCLUSIONS

Our study revealed that recumbency, malnutrition, tube feeding, severe dysphagia and female sex were risk factors for pneumonia. In particular, dysphagia was closely associated with aspiration pneumonia. Moreover, host resistance factors, such as recumbency and malnutrition, also play important roles in the development of aspiration pneumonia.

Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors

BACKGROUND

To investigate prevalence and risk factors for post stroke pneumonia (PSP) in patients with acute ischemic stroke treated at stroke units (SU).

METHOD

We analysed data from the Austrian Stroke Unit registry concerning admissions from January 2003 to December 2013 and assessed the prevalence of PSP at the stroke unit. Patients with and without PSP were compared in univariate and multivariate models searching for factors associated with the occurrence of PSP at the SU.

RESULTS

Three thousand one hundred eleven patients (5.2%) of 59,558 analysed patients were diagnosed with PSP. While age and stroke severity were non-modifiable factors associated with PSP, modifiable risk factors included chronic alcohol consumption and atrial fibrillation. Patients who developed neurological, cardiac, and other infective complications showed a higher prevalence of PSP, an increased prevalence was also found in connection with the placement of nasogastric tubes or urinary catheters. Female sex, left hemispheric stroke, cryptogenic stroke pathogenesis and additionally, treatment with lipid lowering drugs were factors associated with a lower PSP prevalence.

CONCLUSION

Pneumonia in acute ischemic stroke is associated with a variety of modifiable and unmodifiable factors that allow to identify patients at high risk of developing PSP and to focus on early preventive measures at the SU. Further studies could use the results of this study to explore potential benefits of specific interventions targeted at these factors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

How Is Pneumonia Diagnosed in Clinical Stroke Research?

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.

Acid-suppressive medication use in acute stroke and hospital-acquired pneumonia

OBJECTIVE

Pneumonia is a morbid complication of stroke, but evidence-based strategies for its prevention are lacking. Acid-suppressive medications have been associated with increased risk for nosocomial pneumonia in hospitalized patients. It is unclear whether these results can be extrapolated to stroke patients, where other factors strongly modulate pneumonia risk. We investigated the association between acid-suppressive medication and hospital-acquired pneumonia in patients with acute stroke.

METHODS

All patients hospitalized with acute ischemic stroke or intracerebral hemorrhage in a large, urban academic medical center in Boston, Massachusetts from June 2000 to June 2010 who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Acid-suppressive medication use was defined as any pharmacy charge for a proton-pump inhibitor or histamine-2 receptor antagonist. Multivariate logistic regression was used to control for confounders. The main outcome measure was hospital-acquired pneumonia, defined via International Classification of Diseases, Ninth Revision, Clinical Modification codes.

RESULTS

The cohort comprised 1,676 admissions. Acid-suppressive medication was ordered in 1,340 (80%) and hospital-acquired pneumonia occurred in 289 (17.2%). The unadjusted incidence of hospital-acquired pneumonia was higher in the group exposed to acid-suppressive medication compared to those unexposed (20.7% vs 3.6%, odds ratio [OR] = 7.0, 95% confidence interval [CI] = 3.9-12.7). After adjustment, the OR of hospital-acquired pneumonia in the exposed group was 2.3 (95% CI = 1.2-4.6). The association was significant for proton-pump inhibitors (OR = 2.7, 95% CI = 1.4-5.4), but not for histamine-2 receptor antagonists (OR = 1.6, 95% CI = 0.8-3.4).

INTERPRETATION

In this large hospital-based cohort of patients presenting with acute stroke, acid-suppressive medication use was associated with increased odds of hospital-acquired pneumonia.

Are proton pump inhibitors associated with the development of community-acquired pneumonia? A meta-analysis

This study was presented at the American College of Chest Physicians meeting in Pittsburgh (PA, USA) in October 2011. The study objective was to evaluate the association of proton pump inhibitors (PPIs) and community-acquired pneumonia (CAP). The design was a meta-analysis of nine case-controlled and cohort studies. 120,863 pneumonia cases from 1987 to 2006 were included in the meta-analysis. PubMed and Ovid Medline were searched from inception through May 2011 by two investigators independently using keywords: PPI, pneumonia, CAP, anti-ulcer, antacid, omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole. This meta-analysis only included case-controlled and cohort studies that were published in full in English and evaluated PPI use and CAP incidence. Studies were excluded if they included the following patients: pediatric, Helicobacter pylori treatment and critically ill. Bibliographies of recent review articles and systematic reviews were hand-searched. Quality of studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Two investigators independently extracted data into standardized data collection forms that were confirmed by a third investigator. Data were analyzed based on current use of PPIs, duration of PPI use (<30 days or >180 days) and PPI dose (high vs low). Overall association of PPI and CAP was analyzed using the random effects model (Comprehensive Meta analysis(®) Version 2.0). Nine studies met all criteria for the primary outcome. Newcastle-Ottawa Quality Assessment Scale scores ranged from 4 to 8 out of 9. Current use of PPIs (odds ratio [OR]: 1.39; 95% CI: 1.09-1.76), PPI use <30 days (OR: 1.65; 95% CI: 1.25-2.19), PPI high dose (OR: 1.50; 95% CI: 1.33-1.68) and PPI low dose (OR: 1.17; 95% CI: 1.11-1.24) were significantly associated with CAP. There was no association between CAP and PPI use >180 days (OR: 1.10; 95% CI: 1.00-1.21). In conclusion, patients currently receiving PPIs, particularly <30 days or high dose, showed an association with CAP. Practitioners need to be vigilant about adverse effects of PPIs and consider alternative therapies.

Clostridium difficile infection and proton pump inhibitors

PURPOSE OF REVIEW

Clostridium difficile is an intestinal infection associated with antibiotic use, commonly seen in patients with chronic medical issues. The purpose of this review is to discuss the association of C. difficile-associated diarrhea with use of proton pump inhibitors.

RECENT FINDINGS

Multiple medical factors predispose patients to C. difficile-associated diarrhea. Proton pump inhibitors, commonly used for gastric acid suppression, have been shown to have an association with C. difficile-associated diarrhea in both the outpatient and hospital setting. C. difficile-associated diarrhea also has been reported in the pediatric age range linked with proton pump inhibitor use.

SUMMARY

An association exists between C. difficile infection and proton pump inhibitor use. Treatment options exist for C. difficile-associated diarrhea, although judicious use of proton pump inhibitors and antibiotics, emphasis on hand washing, and appropriate use of patient isolation should be implemented as well.

Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis

OBJECTIVE

To systematically review longitudinal studies evaluating use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and risk of pneumonia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline through PubMed, Web of Science with conference proceedings (inception to June 2011), and US Food and Drug Administration website (June 2011). Systematic reviews and references of retrieved articles were also searched.

STUDY SELECTION

Two reviewers independently selected randomised controlled trials and cohort and case-control studies evaluating the use of ACE inhibitors or ARBs and risk of pneumonia and retrieved characteristics of the studies and data estimates.

DATA SYNTHESIS

The primary outcome was incidence of pneumonia and the secondary outcome was pneumonia related mortality. Subgroup analyses were carried according to baseline morbidities (stroke, heart failure, and chronic kidney disease) and patients' characteristics (Asian and non-Asian). Pooled estimates of odds ratios and 95% confidence intervals were derived by random effects meta-analysis. Adjusted frequentist indirect comparisons between ACE inhibitors and ARBs were estimated and combined with direct evidence whenever available. Heterogeneity was assessed using the I(2) test.

RESULTS

37 eligible studies were included. ACE inhibitors were associated with a significantly reduced risk of pneumonia compared with control treatment (19 studies: odds ratio 0.66, 95% confidence interval 0.55 to 0.80; I(2) = 79%) and ARBs (combined direct and indirect odds ratio estimate 0.69, 0.56 to 0.85). In patients with stroke, the risk of pneumonia was also lower in those treated with ACE inhibitors compared with control treatment (odds ratio 0.46, 0.34 to 0.62) and ARBs (0.42, 0.22 to 0.80). ACE inhibitors were associated with a significantly reduced risk of pneumonia among Asian patients (0.43, 0.34 to 0.54) compared with non-Asian patients (0.82, 0.67 to 1.00; P<0.001). Compared with control treatments, both ACE inhibitors (seven studies: odds ratio 0.73, 0.58 to 0.92; I(2)=51%) and ARBs (one randomised controlled trial: 0.63, 0.40 to 1.00) were associated with a decrease in pneumonia related mortality, without differences between interventions.

CONCLUSIONS

The best evidence available points towards a putative protective role of ACE inhibitors but not ARBs in risk of pneumonia. Patient populations that may benefit most are those with previous stroke and Asian patients. ACE inhibitors were also associated with a decrease in pneumonia related mortality, but the data lacked strength.

Malnutrition in patients with acute stroke

Stroke is a devastating event that carries a potential for long-term disability. Malnutrition is frequently observed in patients with stroke, and dysphagia contributes to malnutrition risk. During both the acute phase of stroke and rehabilitation, specific nutritional interventions in the context of a multidisciplinary team effort can enhance the recovery of neurocognitive function. Early identification and management of malnutrition with dietary modifications or specific therapeutic strategies to ensure adequate nutritional intake should receive more attention, since poor nutritional status appears to exacerbate brain damage and to contribute to adverse outcome. The main purpose of nutritional intervention should be the prevention or treatment of complications resulting from energy-protein deficit. This paper reviews the evaluation and management of malnutrition and the use of specialized nutrition support in patients with stroke. Emphasis is given to enteral tube and oral feeding and to strategies to wean from tube feeding.

Risk of fracture and pneumonia from acid suppressive drugs

A recently published systematic review and meta-analysis, incorporating all relevant studies on the association of acid suppressive medications and pneumonia identified up to August 2009, revealed that for every 200 patients, treated with acid suppressive medication, one will develop pneumonia. They showed the overall risk of pneumonia was higher among people using proton pump inhibitors (PPIs) [adjusted odds ratio (OR) = 1.27, 95% CI: 1.11-1.46, I² = 90.5%] and Histamine_-2 receptor antagonists (H₂RAs) (adjusted OR = 1.22, 95% CI: 1.09-1.36, I² = 0.0%). In the randomized controlled trials, use of H₂RAs was associated with an elevated risk of hospital-acquired pneumonia (relative risk 1.22, 95% CI: 1.01-1.48, I² = 30.6%). Another meta-analysis of 11 studies published between 1997 and 2011 found that PPIs, which reduce stomach acid production, were associated with increased risk of fracture. The pooled OR for fracture was 1.29 (95% CI: 1.18-1.41) with use of PPIs and 1.10 (95% CI: 0.99-1.23) with use of H₂RAs, when compared with non-use of the respective medications. Long-term use of PPIs increased the risk of any fracture (adjusted OR = 1.30, 95% CI: 1.15-1.48) and of hip fracture risk (adjusted OR = 1.34, 95% CI: 1.09-1.66), whereas long-term H₂RA use was not significantly associated with fracture risk. Clinicians should carefully consider when deciding to prescribe acid-suppressive drugs, especially for patients who are already at risk for pneumonia and fracture. Since it is unnecessary to achieve an achlorhydric state in order to resolve symptoms, we recommend using the only minimum effective dose of drug required to achieve the desired therapeutic goals.

Risk factors for aspiration pneumonia in frail older people: a systematic literature review

OBJECTIVE

To systematically review the risks for aspiration pneumonia in frail older people and the contribution of bad oral health among the risk factors.

DESIGN

Systematic literature review.

SETTING

PubMed (Medline), Web of Science, Cochrane Library, EMBASE, and CINAHL were searched for eligible studies, published in English in the period January 2000 to April 2009.

PARTICIPANTS

Frail older people.

MEASUREMENTS

Only publications with regard to hospitalized, institutionalized, or frail home-dwelling people of 60 years and older were eligible. Two authors independently assessed the publications for their methodological quality. Unadjusted and adjusted odds ratios and their corresponding 95% confidence intervals for respective risk factors related to aspiration pneumonia were extracted. The results were evaluated according to the levels of evidence of the Oxford Centre for Evidence-based Medicine.

RESULTS

A total of 21 publications fulfilled the quality criteria. Evidence level 2a (systematic review with homogeneity of cohort studies) was found for a positive relationship between aspiration pneumonia and age, male gender, lung diseases, dysphagia, and diabetes mellitus; 2b (individual cohort study) for severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, and bad oral health; 3a (systematic review with homogeneity of case-control studies) for malnutrition; 3b (individual case-control study) for Parkinson's disease and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health among the risk factors seems limited.

CONCLUSION

Thirteen significant risk factors were identified: age, male gender, lung diseases, dysphagia, diabetes mellitus, severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, bad oral health, malnutrition, Parkinson's disease, and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health seems limited.

Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis

BACKGROUND

Observational studies and randomized controlled trials have yielded inconsistent findings about the association between the use of acid-suppressive drugs and the risk of pneumonia. We performed a systematic review and meta-analysis to summarize this association.

METHODS

We searched three electronic databases (MEDLINE [PubMed], Embase and the Cochrane Library) from inception to Aug. 28, 2009. Two evaluators independently extracted data. Because of heterogeneity, we used random-effects meta-analysis to obtain pooled estimates of effect.

RESULTS

We identified 31 studies: five case-control studies, three cohort studies and 23 randomized controlled trials. A meta-analysis of the eight observational studies showed that the overall risk of pneumonia was higher among people using proton pump inhibitors (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.11-1.46, I(2) 90.5%) and histamine(2) receptor antagonists (adjusted OR 1.22, 95% CI 1.09-1.36, I(2) 0.0%). In the randomized controlled trials, use of histamine(2) receptor antagonists was associated with an elevated risk of hospital-acquired pneumonia (relative risk 1.22, 95% CI 1.01-1.48, I(2) 30.6%).

INTERPRETATION

Use of a proton pump inhibitor or histamine(2) receptor antagonist may be associated with an increased risk of both community- and hospital-acquired pneumonia. Given these potential adverse effects, clinicians should use caution in prescribing acid-suppressive drugs for patients at risk.

Derivation and validation of a clinical system for predicting pneumonia in acute stroke

AIMS

We derived and validated a clinical prediction rule that can be used to predict post-stroke pneumonia.

METHODS

We conducted a retrospective cohort study of patients admitted to hospital with a stroke. The cohort was subdivided into a derivation group and a validation group. Within the derivation group, a point scoring system was developed to predict pneumonia based on a logistic regression model. The point scoring system was then tested within the validation group.

RESULTS

Of the 1,363 patients with stroke, 10.5% of patients experienced new pneumonia. The most points were assigned for abnormal swallowing result and history of pneumonia (4 points), followed by greater NIHSS score (3 points), patient being 'found down' at symptom onset (3 points), and age >70 years (2 points). A 3-level classification system was created denoting low, medium and high risks of pneumonia, which accurately predicted pneumonia in the validation group. The discriminatory accuracy of the 3-level clinical prediction rule exceeded the acceptable range in both the derivation group (c statistic: 0.78) and validation group (c statistic: 0.76).

CONCLUSION

A simple scoring system was derived and validated. This clinical scoring system may better identify stroke patients who are at high risk of developing new pneumonia.

Novel preventive and therapuetic strategy for post-stroke pneumonia

Pneumonia is a significant complication of ischemic stroke that increases mortality. Post-stroke pneumonia is defined as newly developed pneumonia following stroke onset. Clinically and chronologically, post-stroke pneumonia is divided into two types of aspiration pneumonia. First, acute-onset post-stroke pneumonia occurs within 1 month after stroke. Second, insidious or chronic-onset post-stroke pneumonia occurs 1 month after the stroke. The mechanisms of pneumonia are apparent aspiration and dysphagia-associated microaspiration. Stroke and the post-stroke state are the most significant risk factors for aspiration pneumonia. The preventive and therapeutic strategies have been developed thoroughly and appropriate antibiotic use, and both pharmacological and nonpharmacological approaches for the treatment of post-stroke pneumonia have been studied rigorously. Increases in substance P levels, oral care, and swallowing rehabilitation are necessary to improve swallowing function in post-stroke patients, resulting in a reduction in the incidence of post-stroke pneumonia in a chronic stage. The stroke must be a cause of aspiration pneumonia.