Nosocomial infections in patients with spontaneous intracerebral hemorrhage

Health Care-Associated Infection in Elderly Patients With Cerebrovascular Disease in Intensive Care Units: A Retrospective Cohort Study in Taizhou, China

BACKGROUND

Cerebrovascular diseases are associated with high incidence of health care-associated infections (HAIs) and poor prognosis in elderly patients. This study aimed to investigate the incidence and clinical characteristics of HAIs in elderly patients with cerebrovascular disease in the intensive care unit (ICU).

METHODS

Patients admitted with cerebrovascular disease, aged ≥65 years, were included. The clinical data of the patients were retrospectively analyzed to determine the risk factors, infection type, distribution, and pathogenic characteristics of HAIs in the context of cerebrovascular diseases.

RESULTS

Out of 381 ICU inpatients monitored, 79 (20.73%) developed HAIs. Risk analysis revealed number of ventilator days as significant risk factors for HAIs in elderly patients with cerebrovascular diseases in the comprehensive ICU. In the HAI group, 56 patients (70.89%) had respiratory tract infection (RTI). Sixty-five patients (82.28%) were infected with Gram-negative bacteria (GNB), and 42 (53.16%) with multi-drug-resistant organism (MDRO). The length of hospitalization days, ventilator days, and overall hospitalization costs were higher in the HAI group than in the non-HAI group (P < 0.05), but there was no significant difference between groups in the treatment outcome of patients. Patients with MDRO infection had longer duration and higher cost of hospitalization than those infected with non-MDRO (P < 0.05), but there was no significant difference between the groups in the treatment outcome of patients.

CONCLUSIONS

HAIs occurred mostly due to RTI and GNB infection. The hospitalization cost and duration, as well as the length of ventilator days, were higher for cerebrovascular patients with HAIs than for non-HAIs patients.

Systemic Inflammation after Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is one of the most severe neurological disorders, with a high mortality rate and severe disabling functional sequelae. Systemic inflammation following hemorrhagic stroke may play an important role in mediating intracranial and extracranial tissue damage. Previous studies showed that various systemic inflammatory biomarkers might be useful in predicting clinical outcomes. Anti-inflammatory treatment might be a promising therapeutic approach for improving the prognosis of patients with aSAH. This review summarizes the complicated interactions between the nervous system and the immune system.

Ruptured arteriovenous malformation mortality: Incidence, risk factors, and inpatient outcome score

BACKGROUND

Limited literature exists on the morbidity and mortality of AVM associated intracerebral hemorrhage (ICH) compared with non-AVM ICH.

OBJECTIVE

We examine morbidity and mortality in cAVM in a large nationwide inpatient sample to create a prognostic inpatient ruptured AVM mortality score.

METHODS

This retrospective cohort study from 2008 to 2014 compares outcomes in cAVM related hemorrhages and ICH utilizing the National Inpatient Sample database. Diagnostic codes for ICH and AVM underlying ICH were identified. We compared case fatality according to medical complications. Multivariate analysis was used to derive hazard ratios and 95% confidence intervals to assess odds of mortality.

RESULTS

We identified 6496 patients with ruptured AVMs comparing them to 627,185 admitted with ICH. Mortality was lower for ruptured AVMs (11%) compared to ICH (22%) [p < 0.01]. Mortality associated factors were liver disease (OR 2.64, CI 1.81-3.85, p < .001), diabetes mellitus (OR 2.42, CI 1.38-4.22, p = 0.002), alcohol abuse (OR 1.81, CI 1.31-2.49, p = 0.001), hydrocephalus (OR 3.35 CI 2.81-4.00, p < 0.001), cerebral edema (OR 1.5, 1.25-1.85, p < 0.001), cardiac arrest (OR 15, CI 7.9-30, p < 0.001), and pneumonia (OR 1.93, CI 1.51-2.47, p < 0.001). A 0-5 ruptured AVM mortality score was developed: Cardiac arrest (=3), age >60 (=1), Black race (=1), chronic liver failure (=1) diabetes mellitus (=1), pneumonia (=1), alcohol abuse (=1) and cerebral edema (=1). Mortality increased with score. No patient with 5 or more points survived.

CONCLUSION

The Ruptured AVM Mortality Score allows for risk stratification on patients with ICH due to ruptured AVM. This scale could prove useful in prognostication and patient education.

One-Year Outcome Trajectories and Factors Associated with Functional Recovery Among Survivors of Intracerebral and Intraventricular Hemorrhage With Initial Severe Disability

Importance

Patients who survive severe intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) typically have poor functional outcome in the short term and understanding of future recovery is limited.

Objective

To describe 1-year recovery trajectories among ICH and IVH survivors with initial severe disability and assess the association of hospital events with long-term recovery.

Design, Setting, and Participants

This post hoc analysis pooled all individual patient data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 trial (CLEAR-III) and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation (MISTIE-III) phase 3 trial in multiple centers across the US, Canada, Europe, and Asia. Patients were enrolled from August 1, 2010, to September 30, 2018, with a follow-up duration of 1 year. Of 999 enrolled patients, 724 survived with a day 30 modified Rankin Scale score (mRS) of 4 to 5 after excluding 13 participants with missing day 30 mRS. An additional 9 patients were excluded because of missing 1-year mRS. The final pooled cohort included 715 patients (71.6%) with day 30 mRS 4 to 5. Data were analyzed from July 2019 to January 2022.

Exposures

CLEAR-III participants randomized to intraventricular alteplase vs placebo. MISTIE-III participants randomized to stereotactic thrombolysis of hematoma vs standard medical care.

Main Outcomes and Measures

Primary outcome was 1-year mRS. Patients were dichotomized into good outcome at 1 year (mRS 0 to 3) vs poor outcome at 1 year (mRS 4 to 6). Multivariable logistic regression models assessed associations between prospectively adjudicated hospital events and 1-year good outcome after adjusting for demographic characteristics, ICH and IVH severity, and trial cohort.

Results

Of 715 survivors, 417 (58%) were male, and the overall mean (SD) age was 60.3 (11.7) years. Overall, 174 participants (24.3%) were Black, 491 (68.6%) were White, and 49 (6.9%) were of other races (including Asian, Native American, and Pacific Islander, consolidated owing to small numbers); 98 (13.7%) were of Hispanic ethnicity. By 1 year, 129 participants (18%) had died and 308 (43%) had achieved mRS 0 to 3. In adjusted models for the combined cohort, diabetes (adjusted odds ratio [aOR], 0.50; 95% CI, 0.26-0.96), National Institutes of Health Stroke Scale (aOR, 0.93; 95% CI, 0.90-0.96), severe leukoaraiosis (aOR, 0.30; 95% CI, 0.16-0.54), pineal gland shift (aOR, 0.87; 95% CI, 0.76-0.99]), acute ischemic stroke (aOR, 0.44; 95% CI, 0.21-0.94), gastrostomy (aOR, 0.30; 95% CI, 0.17-0.50), and persistent hydrocephalus by day 30 (aOR, 0.37; 95% CI, 0.14-0.98) were associated with lack of recovery. Resolution of ICH (aOR, 1.82; 95% CI, 1.08-3.04) and IVH (aOR, 2.19; 95% CI, 1.02-4.68) by day 30 were associated with recovery to good outcome. In the CLEAR-III model, cerebral perfusion pressure less than 60 mm Hg (aOR, 0.30; 95% CI, 0.13-0.71), sepsis (aOR, 0.05; 95% CI, 0.00-0.80), and prolonged mechanical ventilation (aOR, 0.96; 95% CI, 0.92-1.00 per day), and in MISTIE-III, need for intracranial pressure monitoring (aOR, 0.35; 95% CI, 0.12-0.98), were additional factors associated with poor outcome. Thirty-day event-based models strongly predicted 1-year outcome (area under the receiver operating characteristic curve [AUC], 0.87; 95% CI, 0.83-0.90), with significantly improved discrimination over models using baseline severity factors alone (AUC, 0.76; 95% CI, 0.71-0.80; P < .001).

Conclusions and Relevance

Among survivors of severe ICH and IVH with initial poor functional outcome, more than 40% recovered to good outcome by 1 year. Hospital events were strongly associated with long-term functional recovery and may be potential targets for intervention. Avoiding early pessimistic prognostication and delaying prognostication until after treatment may improve ability to predict future recovery.

Braden scale for predicting pneumonia after spontaneous intracerebral hemorrhage

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Combined PK/PD Index May Be a More Appropriate PK/PD Index for Cefoperazone/Sulbactam against Acinetobacter baumannii in Patients with Hospital-Acquired Pneumonia

Cefoperazone/sulbactam (CPZ/SUL) is a β-lactam and β-lactamase inhibitor combination therapy for the treatment of respiratory tract infections. Using data from a prospective, multiple-center, open-label clinical trial in 54 patients with hospital-acquired pneumonia or ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii (Ab), we showed that a combined PK/PD index %(T > MICcpz*T > MICsul) is a more appropriate PK/PD index against Ab, compared to the PK/PD index (%T > MIC) for a single drug. For a 2 h infusion, the PK/PD cutoff of CPZ/SUL (2 g/1 g, q8h) for clinical and microbiological efficacy was 4/2 and 1/0.5 mg/L, respectively. The corresponding cumulative fraction of response was 46.5% and 25.3%, respectively. Results based on the combined PK/PD index were quite similar to that based on the joint probability of target attainment. The two drugs have interaction from the viewpoint of PK/PD. When the dose of one drug was too high, the PK/PD cutoff was often determined by another drug in which the dose was maintained. In most cases, sulbactam exerted the main effect against infection by Ab in the complex CPZ/SUL, which was similar to the literature reports. When the MIC of CPZ was 8, 16, or 32 mg/L, a CPZ/SUL 2 g/1 g (q8h), 2 g/2 g (q8h), or 2 g/2 g (q6h) (infusion was all 3 h) was recommended, respectively. A clinical efficacy and safety study to confirm simulation results is warranted.

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

ABSTRACT

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

Risk Factors for Stroke Associated Pneumonia

BACKGROUND:

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

AIM:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

Healthcare-Associated Infections in the Neurocritical Care Unit

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

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

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

Nosocomial Infections among Patients with Intracranial Hemorrhage: A Retrospective Data Analysis of Predictors and Outcomes

OBJECTIVE

Intracranial hemorrhage is a critical medical emergency. Nosocomial infections may promote worse outcomes in these vulnerable patients. This study investigated microbial features, predictors, and clinical outcomes of nosocomial infections among patients with multiple subtypes of intracranial hemorrhage.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients that were hospitalized with intracranial hemorrhage between January 2015 and October 2018, and divided them into two groups based on the development of nosocomial infection. Within the cohort of patients with nosocomial infections, microbiology and resistance patterns were established across multiple sites of infection. Moreover, consequences of nosocomial infection such as mortality and length of hospital stay were determined.

RESULTS

A total of 233 cases were identified that met our inclusion and exclusion criteria out of which were 94 cases of nosocomial infection (40.3%) versus 139 cases with no nosocomial infection (59.7%). The most common infections were pneumonia, urinary tract infections, and bacteremia. Resistance accounted for 70.2% of cultures. Multivariable analysis revealed significant association of nosocomial infections with hypertension (OR: 2.62, 95% CI: 1.11-6.16, p = 0.027), hospital LOS (OR: 1.08, 95% CI: 1.05-1.12, p < 0.001), levetiracetam (OR: 3.6, 95% CI: 1.41-0.922, p = 0.007), and GCS category (OR: 5.42, 95% CI: 1.67-17.55, p = 0.005 and OR: 7.63, 95% CI: 2.44-23.87, p < 0.001 for moderate and severe, respectively). Patients with nosocomial infections witnessed a significant increase in the length of hospital stay (23 versus 8 hospital days, p < 0.001). This finding was significant across most types of brain hemorrhage. Mortality was significantly associated with GCS category (OR: 10.1, 95% CI: 4-25.7, p < 0.001) and percutaneous endoscopic gastrostomy tube insertion (OR: 19.6, 95% CI: 4.1-91, p < 0.001).

CONCLUSIONS

Collectively, these findings suggest that nosocomial infections are common among patients with intracranial hemorrhage and can be predictable by considering certain risk factors. Future studies are warranted to evaluate the efficacy of implementing infection control strategies or protocols on these patients to achieve better therapeutic outcomes.

Frequency of post-stroke pneumonia: Systematic review and meta-analysis of observational studies

Background

Post-stroke pneumonia and other infectious complications are serious conditions whose frequency varies widely across studies.

Aims

We conducted a systematic review to estimate the frequency of post-stroke pneumonia and other types of major infection.

Summary of review

MEDLINE, EMBASE, CINAHL, and PsycINFO databases were searched for prospective studies with consecutive recruitment of stroke patients. The primary outcome was post-stroke pneumonia. Secondary outcomes were any infection and urinary tract infection. Quality assessment was done using Newcastle Ottawa scale. Heterogeneity of estimates across study populations was calculated using Cochran's Q (heterogeneity χ2) and I2 statistics. A total of 47 studies (139,432 patients) with 48 sample populations were eligible for inclusion. Mean age of patients was 68.3 years and their mean National Institute of Health Stroke Scale score was 8.2. The pooled frequency of post-stroke pneumonia was 12.3% (95% confidence interval [CI] 11%–13.6%; I2 = 98%). The pooled frequency from 2011 to 2017 was 13.5% (95% CI 11.8%–15.3%; I2 = 98%) and comparable with earlier periods (P interaction = 0.31). The pooled frequency in studies in stroke units was 8% (95% CI 7.1%–9%; I2 = 78%) and significantly lower than other locations (P interaction = 0.001). The pooled frequency of post-stroke infection was 21% (95% CI 13%–29.3%; I2 = 99%) and of post-stroke urinary tract infection was 7.9% (95% CI 6.7%–9.3%; I2 = 96%).

Conclusion

Approximately 1 in 10 stroke patients experience pneumonia during the acute period of hospital care. The frequency of post-stroke pneumonia has remained stable in recent decades but is lower in patients receiving stroke unit care compared to management in other ward settings.

Bacterial Distribution and Risk Factors of Nosocomial Blood Stream Infection in Neurologic Patients in the Intensive Care Unit

OBJECTIVE

To investigate the risk factors and analyze the distribution of pathogens to provide a basis for the prevention of nosocomial blood stream infections (BSI) and reduce the incidence and mortality of nosocomial BSI in neurologic patients.

PATIENTS AND METHODS

A retrospective chart review of neurologic patients admitted to an adult intensive care unit from January 2012 to December 2017 was conducted. Every positive blood culture, clinical demographic, microbiologic and laboratory result, as well as 28-day outcome data, were compiled on a data collection sheet. The clinical significance of each isolate was determined; in addition, the antimicrobial susceptibilities of causative pathogens and the most likely source were recorded.

RESULTS

During the five-year study period, there were 121 nosocomial BSI yielding 151 isolates in 404 neurologic patients. Eighty-one percent of nosocomial BSI were monomicrobial. Gram-positive organisms caused 67.9% of these BSI, gram-negative organisms caused 32.1%, and fungi caused 0.8%. The crude incidence rate was approximately 29.9%, and the mortality of nosocomial BSI was as high as 29.8%. Intravascular lines were the most common source of nosocomial BSI (79.3%). The most common organisms causing BSI were coagulase-negative staphylococci (CoNS; 44.6% of isolates), Staphylococcus aureus (17.4%), Klebsiella species (11.5%), and Acinetobacter spp. (11.5%). Multivariable regression analysis revealed that the use of antibiotic agents in the 90 days prior (odds ratio [OR], 5.81; 95% confidence interval [CI], 3.18-10.62; p = 0.001), brain trauma (OR, 0.28; 95% CI, 0.15-0.51; p = 0.001), and transfusion (OR, 3.02; 95% CI, 1.45-6.29; p = 0.001) were significant predictors of nosocomial BSI.

CONCLUSIONS

The incidence and mortality of nosocomial BSI were high in our neurologic patients. Strictly aseptic operations, hand hygiene, and reasonable use of transfusions and antibiotic agents are effective measures to prevent nosocomial BSI.

Applicability, Safety, and Cost-Effectiveness of Improvised External Ventricular Drainage: An Observational Study of Tunisian Neurosurgery Inpatients

OBJECTIVE

External ventricular drainage (EVD) is an emergent neurosurgical procedure. Many commercial sets are available for EVD that are not always obtainable in all hospitals. The aim of our study was to describe new techniques to perform EVD using simple improvised materials to check the real-world applicability of the same device in the management of acute hydrocephalus and its effectiveness and safety.

METHODS

We illustrated 2 techniques for a "do it yourself" improvised EVD device using materials available even in non-neurosurgery-dedicated operating rooms. We performed an observational study in our institution (April 2015 to December 2016). We included all patients presenting with acute hydrocephalus and requiring EVD.

RESULTS

During a 20-month period, the new EVD device was used as a lifesaving solution for 33 patients. Good outcomes were noted in 11 of the 33 patients (33%). The EVD was complicated by fatal meningitis in 4 of the patients (12%). Malfunction occurred in 6 patients. The new EVD device costs less than US$20 for the first technique and less than US$10 for the second technique. In contrast, the cost of a standard EVD set ranges from US$170 to US$380 in Tunisia.

CONCLUSIONS

The new EVD device has the potential to improve the quality of efficiency of care in difficult economic times that have changed the medical landscape, because it is both easy to make and cost-effective. Because it is an inexpensive technique, it could also be suitable for low-income countries, where neurosurgery is not yet the first and foremost health priority.

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

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.

Cerebrospinal Fluid Presepsin As a Marker of Nosocomial Infections of the Central Nervous System: A Prospective Observational Study

Background

Nosocomial CNS infection (NI-CNS) is a common and serious complication in neurocritical care patients. Timely, accurate diagnosis of NI-CNS is crucial, yet current infection markers lack specificity and/or sensitivity. Presepsin (PSP) is a novel biomarker of macrophage activation. Its utility in NI-CNS has not been explored. We first determined the normal range of cerebrospinal fluid (CSF) PSP in a control group without brain injury before collecting data on CSF PSP levels in neurocritical care patients. Samples were analyzed in four groups defined by systemic and neurological infection status.

Results

CSF PSP levels in 15 control patients without neurological injury were 50–100 pg/ml. Ninety-seven CSF samples were collected from 21 neurocritical care patients. In patients without NI-CNS or systemic infection, CSF PSP was 340.4 ± 201.1 pg/ml. Isolated NI-CNS was associated with CSF PSP levels of 640.8 ± 235.5 pg/ml, while levels in systemic infection without NI-CNS were 580.1 ± 329.7 pg/ml. Patients with both NI-CNS and systemic infection had CSF PSP levels of 1,047.7 ± 166.2 pg/ml. In neurocritical care patients without systemic infection, a cut-off value of 321 pg/ml gives sensitivity and specificity for NI-CNS of 100 and 58.3%, respectively.

Conclusion

CSF PSP may prove useful in diagnosing NI-CNS, but its current utility is as an additional marker only.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neuroinvasive Infection from O117:K52:H-Escherichia colifollowing Acute Pyelonephritis

Spontaneous or nosocomial Escherichia coli meningitis remains rare in healthy adults but is still carrying a high mortality rate despite adapted antimicrobial treatment for susceptible strains. A 39-year-old woman was admitted to the hospital with severe subarachnoid haemorrhage complicated by acute hydrocephalus. On hospital day 10, she developed Streptococcus anginosus septicaemia and urinary tract infection due to a multisensitive strain of E. coli. This infection was successfully controlled by antimicrobial therapy. As a late complication in the neurosurgical ward (day 39), she developed fever, alteration of consciousness, and shock, leading to the diagnosis of bacterial meningitis. The culture of blood, cerebrospinal fluid, and urine grew positive for a multisensitive E. coli. The strain was identified as O117:K52:H, a serotype that was until now never associated with acute meningitis or brain abscesses. The source appeared to be the urinary tract with the demonstration of acute pyelonephritis. The patient died on day 94 from delayed complications of multiple brain abscesses.

Predictors of Acute Kidney Injury in Neurocritical Care Patients Receiving Continuous Hypertonic Saline

BACKGROUND AND PURPOSE

Continuous intravenous 3% hypertonic saline (HTS) infusions are commonly used for the management of cerebral edema following severe neurologic injuries. Despite widespread use, data regarding the incidence and predictors of nephrotoxicity are lacking. The purpose of this study was to describe the incidence and identify predictors of acute kidney injury (AKI) in neurocritical care patients administered continuous infusion HTS.

METHODS

This was an institutional review board-approved, multicenter, retrospective cohort study of patients receiving HTS infusions at 2 academic medical centers. A univariate analysis and multivariable logistic regression were used to identify predictors of AKI. Data regarding AKI were evaluated during treatment with HTS and up to 24 hours after discontinuation.

RESULTS

A total of 329 patients were included in our analysis, with 54 (16%) developing AKI. Those who developed AKI experienced significantly longer stays in the intensive care unit (14.8 vs 11.5 days; P = .006) and higher mortality (48.1% vs 21.9%; P < .001). We identified past medical history of chronic kidney disease (odds ratio [OR]: 9.7, 95% confidence interval [CI]: 1.9-50.6; P = .007), serum sodium greater than 155 mmol/L (OR: 4.1, 95% CI: 2.1-8.0; P < .001), concomitant administration of piperacillin/tazobactam (OR: 3.9, 95% CI: 1.7-9.3; P = .002), male gender (OR: 3.2, 95% CI: 1.5-6.6; P = .002), and African American race (OR: 2.6, 95% CI: 1.3-5.2; P = .007) as independent predictors of AKI.

CONCLUSION

Acute kidney injury is relatively common in patients receiving continuous HTS and may significantly impact clinical outcomes.