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Stroke-associated pneumonia according to mCDC criteria: impact on prognosis and antibiotic therapy
Neus Rabaneda-Lombarte1, Júlia Faura2, Garbiñe Ezcurra-Díaz1
1Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain.
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.
Insights
The modified Centers for Disease Control and Prevention (mCDC) criteria may help identify stroke-associated pneumonia (SAP) linked to poor outcomes. Fever, not strict adherence to criteria, often triggers antibiotic use in stroke patients.
Area of Science:
- Neurology
- Infectious Diseases
- Clinical Medicine
Background:
- Stroke-associated pneumonia (SAP) is a common complication affecting stroke patient outcomes.
- The modified Centers for Disease Control and Prevention (mCDC) criteria aim to standardize SAP diagnosis and management.
- The clinical relevance and impact of SAP, particularly concerning the mCDC criteria, require further investigation.
Purpose of the Study:
- To evaluate the impact of SAP conforming to mCDC criteria (mCDC-SAP) versus other pneumonias (OPn) on stroke outcomes.
- To identify factors influencing the initiation of antibiotic therapy in stroke patients.
Main Methods:
- A prospective, multicenter observational study involving ischemic stroke patients with NIHSS≥4.
- Daily assessment of mCDC criteria, infections, and antibiotic use for 7 days post-admission.
- Logistic regression and random forest analyses to determine predictors of poor outcome and antibiotic initiation.
Main Results:
- Of 342 patients, 39 had pneumonia (11.7%), with 25 (7.5%) meeting mCDC criteria.
- mCDC-SAP was an independent predictor of poor 3-month outcome (OR, 4.939).
- Fever was the most important factor for antibiotic initiation, more so than adherence to mCDC criteria.
Conclusions:
- The mCDC criteria may effectively identify clinically significant SAP associated with adverse outcomes.
- Antibiotic initiation in stroke patients is often driven by isolated infection signs like fever.
- Adherence to mCDC criteria could potentially lead to antibiotic stewardship without compromising patient outcomes.
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