Journal of Neurology

, 254:1323

Predictors of pneumonia in acute stroke patients admitted to a neurological intensive care unit

  • Uwe Walter
  • Rupert Knoblich
  • Volker Steinhagen
  • Martina Donat
  • Reiner Benecke
  • Antje Kloth
ORIGINAL COMMUNICATION
  • 585 Downloads

Abstract

Objective

To determine independent clinical predictors of stroke-associated pneumonia (SAP) that are available in all patients on day of hospital admission.

Methods

We studied 236 patients with acute ischemic stroke admitted to the neurological intensive care unit at our university hospital. Risk factors of SAP and of non-responsivity of early-onset pneumonia (EOP; onset within 72 hours after admission) to initial antibacterial treatment were analyzed.

Results

Incidence of SAP was 22%. The following independent risk factors were found to predict SAP with 76% (EOP: 90%) sensitivity and 88% specificity: dysphagia (RR, 9.92; 95% CI, 5.28-18.7), National Institute of Health Stroke Scale − 10 (RR, 6.57; CI, 3.36-12.9), non-lacunar basal-ganglia infarction (RR, 3.10; CI, 1.17-5.62), and any other infection present on admission (RR, 3.78; CI, 2.45-5.83). Excluding the patients with other infections on admission, the same independent risk factors (except infection) were found. Further, but not independent risk factors were: combined brainstem and cerebellar infarction, infarction affecting more than 66% of middle cerebral artery territory, hemispheric infarction exceeding middle cerebral artery territory, impaired vigilance, mechanical ventilation, age − 73 years, current malignoma, and cardioembolic stroke, whereas patients with lacunar infarctions had significantly lower risk. In contrast to previous reports, no impact of male gender or diabetes was found. Initial vomiting, especially if associated with impaired vigilance, predicted antibacterial treatment non-responsivity of EOP. In nonresponders exclusively fungal pathogens were identified.

Conclusion

Increased risk of pneumonia in acute stroke patients can be sufficiently predicted by a small set of clinical risk factors.

Key words

pneumonia dysphagia basal ganglia ischemic stroke stroke-induced immunosuppression 

References

  1. 1.
    Hilker R, Poetter C, Findeisen N, Sobesky J, Jacobs A, Neveling M, Heiss WD (2003) Nosocomial pneumonia after acute stroke: implications for neurological intensive care medicine. Stroke 34:975-81CrossRefPubMedGoogle Scholar
  2. 2.
    Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW (2003) The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology 60:620-25PubMedGoogle Scholar
  3. 3.
    Upadya A, Thorevska N, Sena KN, Manthous C, Amoateng-Adjepong Y (2004) Predictors and consequences of pneumonia in critically ill patients with stroke. J Crit Care 19:16-2CrossRefPubMedGoogle Scholar
  4. 4.
    Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S; Stroke Practice Improvement Network Investigators (2005) Formal dysphagia screening protocols prevent pneumonia. Stroke 36:1972-976CrossRefPubMedGoogle Scholar
  5. 5.
    Hamidon BB, Raymond AA, Norlinah MI, Jefferelli SB (2003) The predictors of early infection after an acute ischaemic stroke. Singapore Med J 44:344-46PubMedGoogle Scholar
  6. 6.
    Aslanyan S, Weir CJ, Diener HC, Kaste M, Lees KR; GAIN International Steering Committee, Investigators (2004) Pneumonia and urinary tract infection after acute ischaemic stroke: a tertiary analysis of the GAIN International trial. Eur J Neurol 11:49-3CrossRefPubMedGoogle Scholar
  7. 7.
    Meisel C, Prass K, Braun J, Victorov I, Wolf T, Megow D, Halle E, Volk HD, Dirnagl U, Meisel A (2004) Preventive antibacterial treatment improves the general medical and neurological outcome in a mouse model of stroke. Stroke 35:2-CrossRefPubMedGoogle Scholar
  8. 8.
    Sirvent JM, Torres A, El-Ebiary M, Castro P, de Batlle J, Bonet A (1997) Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 155:1729-734PubMedGoogle Scholar
  9. 9.
    Chamorro A, Horcajada JP, Obach V, Vargas M, Revilla M, Torres F, Cervera A, Planas AM, Mensa J (2005) The Early Systemic Prophylaxis of Infection After Stroke study: a randomized clinical trial. Stroke 36:1495-500CrossRefPubMedGoogle Scholar
  10. 10.
    Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, Rorick M, Moomaw CJ, Walker M (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20:864-70PubMedGoogle Scholar
  11. 11.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81-4CrossRefPubMedGoogle Scholar
  12. 12.
    Collins MJ, Bakheit AM (1997) Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke 28:1773-775PubMedGoogle Scholar
  13. 13.
    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35-1PubMedGoogle Scholar
  14. 14.
    Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM (1988) CDC definitions for nosocomial infections, 1988. Am J Infect Control 16:128-40CrossRefPubMedGoogle Scholar
  15. 15.
    Langer M, Mosconi P, Cigada M, Mandelli M (1989) Long-term respiratory support and risk of pneumonia in critically ill patients. Intensive Care Unit Group of Infection Control. Am Rev Respir Dis 140:302-05PubMedGoogle Scholar
  16. 16.
    Marik PE (2001) Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 344:665-71CrossRefPubMedGoogle Scholar
  17. 17.
    Johnson JL, Hirsch CS (2003) Aspiration pneumonia. Recognizing and managing a potentially growing disorder. Postgrad Med 113:99-02,105-06,111-12PubMedGoogle Scholar
  18. 18.
    Campinos L, Duval G, Couturier M, Brage D, Pham J, Gaudy JH (1983) The value of early fibreoptic bronchoscopy after aspiration of gastric contents. Br J Anaesth 55:1103-105CrossRefPubMedGoogle Scholar
  19. 19.
    Kolominsky-Rabas PL, Sarti C, Heuschmann PU, Graf C, Siemonsen S, Neundoerfer B, Katalinic A, Lang E, Gassmann KG, von Stockert TR (1998) A prospective community-based study of stroke in Germany - the Erlangen Stroke Project (ESPro): incidence and case fatality at 1, 3, and 12 months. Stroke 29:2501-506PubMedGoogle Scholar
  20. 20.
    Gostynski M, Engelter S, Papa S, Ajdacic-Gross V, Gutzwiller F, Lyrer P (2006) Incidence of first-ever ischemic stroke in the Canton Basle-City, Switzerland: a population-based study 2002/2003. J Neurol 253:86-1CrossRefPubMedGoogle Scholar
  21. 21.
    Meisinger C, Heier M, Volzke H, Lowel H, Mitusch R, Hense HW, Ludemann J (2006) Regional disparities of hypertension prevalence and management within Germany. J Hypertens 24:293-99CrossRefPubMedGoogle Scholar
  22. 22.
    Dettenkofer M, Ebner W, Els T, Babikir R, Lucking C, Pelz K, Ruden H, Daschner F (2001) Surveillance of nosocomial infections in a neurology intensive care unit. J Neurol 248:959-64CrossRefPubMedGoogle Scholar
  23. 23.
    Nakagawa T, Sekizawa K, Arai H, Kikuchi R, Manabe K, Sasaki H (1997) High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch Intern Med 157:321-24CrossRefPubMedGoogle Scholar
  24. 24.
    Gendron A, Teitelbaum J, Cossette C, Nuara S, Dumont M, Geadah D, du Souich P, Kouassi E (2002) Temporal effects of left versus right middle cerebral artery occlusion on spleen lymphocyte subsets and mitogenic response in Wistar rats. Brain Res 955:85-7CrossRefPubMedGoogle Scholar
  25. 25.
    ECRI Health Technology Assessment Group (1999) Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients. Evid Rep Technol Assess (Summ) 8:1-Google Scholar
  26. 26.
    Doggett DL, Tappe KA, Mitchell MD, Chapell R, Coates V, Turkelson CM (2001) Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature. Dysphagia 16:279-95CrossRefPubMedGoogle Scholar
  27. 27.
    Teasell R, Foley N, Fisher J, Finestone H (2002) The incidence, management, and complications of dysphagia in patients with medullary strokes admitted to a rehabilitation unit. Dysphagia 17:115-20CrossRefPubMedGoogle Scholar
  28. 28.
    Dziewas R, Ritter M, Schilling M, Konrad C, Oelenberg S, Nabavi DG, Stogbauer F, Ringelstein EB, Ludemann P (2004) Pneumonia in acute stroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry 75:852-56CrossRefPubMedGoogle Scholar
  29. 29.
    Prass K, Meisel C, Hoflich C, Braun J, Halle E, Wolf T, Ruscher K, Victorov IV, Priller J, Dirnagl U, Volk HD, Meisel A (2003) Stroke-induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke T helper cell type 1-like immunostimulation. J Exp Med 198:725-36CrossRefPubMedGoogle Scholar
  30. 30.
    Prass K, Braun JS, Dirnagl U, Meisel C, Meisel A (2006) Stroke propagates bacterial aspiration to pneumonia in a model of cerebral ischemia. Stroke 37:2607-612CrossRefPubMedGoogle Scholar

Copyright information

© Steinkopff-Verlag 2007

Authors and Affiliations

  • Uwe Walter
    • 1
  • Rupert Knoblich
    • 1
  • Volker Steinhagen
    • 1
  • Martina Donat
    • 2
  • Reiner Benecke
    • 1
  • Antje Kloth
    • 1
    • 3
  1. 1.Dept. of NeurologyUniversity of RostockRostockGermany
  2. 2.Dept. of Medical Microbiology & Hospital HygieneUniversity of RostockRostockGermany
  3. 3.Geriatric Rehabilitation HospitalTessinGermany

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