Brain Trauma Stroke
Post-stroke Infections – Diagnosis, Prediction, Prevention and Treatment to Improve Patient Outcomes
Hendrik Harms,1 Elke Halle2 and Andreas Meisel3
1. Clinical Scientist, Centre for Stroke Research Berlin, and Attending Neurologist, Department of Neurology, Charité Medical University Berlin; 2. Clinical Scientist, and Attending Microbiologist, Institute for Microbiology and Hygiene; 3. Professor of Neurology, NeuroCure Clinical Research Centre and Centre for Stroke Research Berlin, and Attending Physician, and Neurointensivist, Department of Neurology, Charité Medical University Berlin
Abstract
Despite modern stroke treatment in dedicated stroke units and rehabilitation facilities, infection remains the most important medical complication after ischaemic stroke. Pneumonia and urinary tract infections are the most frequent post-stroke infections. Post-stroke infections not only prolong hospitalisation but also constitute a leading cause of early and long-term mortality and morbidity. They are commonly attributed to neurological sequelae such as immobilisation due to motor paralysis or dysphagia as a risk of aspiration. Recently, stroke-induced impairment of immunological competence has been described. This immunodepression syndrome promotes the development of post-stroke infection. Knowledge about risk factors for post-stroke infections, early and proper diagnosis and a deliberate decision for anti-infective treatment are of evident importance, but all of these are considered major challenges for stroke neurologists. In this article we will discuss new insights into diagnostic approaches and risk factors for post-stroke infections. Furthermore, we will focus on preventative approaches and the current treatment options.
Keywords Ischaemic stroke, pneumonia, urinary tract infection, immunodepression, diagnostic, prevention, treatment
Disclosure: Hendrik Harms and Elke Halle have received speaker’s honoraria from Bayer Vital GmbH. Andreas Meisel has received speaker’s honoraria from Bayer Vital GmbH and Wyeth Pharma GmbH. A patent application on anti-infective agents and immunomodulators used for preventative therapy following an acute cerebrovascular accident has been filed to the European Patent Office (PCT/EP03/02246): patent owner Charité Universitaetsmedizin Berlin, patent inventors Andreas Meisel and Elke Halle. Received: 20 May 2010 Accepted: 28 June 2010 Citation: European Neurological Review, 2010;5(1):39–43 Correspondence: Andreas Meisel, Centre of Stroke Research Berlin, Department of Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany. E:
andreas.meisel@
charite.de
Up to 95% of patients have at least one relevant complication within the first three months after stroke.1 neurological outcomes2–4
Complications impair and approximately one-third of patients
To minimise the impact of stroke-associated adverse events, patients should be treated in specialised units where complications are detected earlier compared with general units. In addition, treatment in stroke units improves survival by preventing life-threatening situations.3
with ischaemic stroke die during hospitalisation due to one or more complications.5
However, even in specialised stroke units, stroke-associated infections remain one of the major complications in acute stroke, with frequencies between 21 and 65%.6
The incidence of infection among
stroke patients is thus significantly higher than the general prevalence of hospital-acquired infection, which ranges from 6 to 9% in all hospitalised patients.7,8
Bacterial pneumonia and urinary tract infection (UTI) are the predominant infections in acute stroke patients.2,9
The incidence of
This compares with an average rate of pneumonia of only 3.5% in non-stroke patients treated in a geriatric hospital.13 In the general population, the risk of UTI is between 3 and 10% per day of catheterisation.14,15
© TOUCH BRIEFINGS 2010
UTI in acute stroke ranges between 6 and 27%, whereas the frequency of stroke-associated pneumonia (SAP) lies between 5 and 22%.6,10–12
Diagnosis of Post-stroke Infections Post-stroke Pneumonia
Traditionally, the diagnosis of pneumonia requires a combination of clinical assessment, radiological imaging and appropriate microbiological tests; however, a reliable diagnosis of pneumonia remains a medical challenge, even in stroke patients. Unspecific symptoms of respiratory infection are fever or hypothermia, cough, purulent secretion, dyspnoea, myalgia, arthralgia, headache and delirium; therefore, clinical examinations alone do not improve diagnostic properties. Radiological examination and microbiological tests are mandatory to establish the diagnosis of classic (bacterial) pneumonia. This is reasonable because plain chest radiography is an inexpensive test and an important initial examination in all patients with suspected pneumonia.16
However, diagnostic properties are limited even in immobilised stroke patients.17,18
Computed tomography (CT) is a valuable adjunct in negative or non- diagnostic chest radiography, unresolved pneumonias and when complications are suspected.19
However, even in current Centers for
Disease Control and Prevention (CDC) guidelines, chest radiography remains the central diagnostic tool.
In stroke patients, we recommend the use of the criteria for a ‘clinically defined pneumonia’ (see Table 1) in which diagnosis is possible without further microbiological tests.
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