Stroke-associated pneumonia according to mCDC criteria: impact on prognosis and antibiotic therapy

Abstract

Antibiotics; Infections; Stroke-associated pneumonia

Antibióticos; Infecciones; Neumonía asociada a ictus

Antibiòtics; Infeccions; Pneumònia associada a ictus

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.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. Study supported by Fundació La Marató de TV3 (201706-30-31), Instituto de Salud Carlos III (PI17/02130 and PI21/00949), co-financed by the Fondo Europeo de Desarrollo Regional. Some centres take part in Spanish Stroke Research Network RICORS-ICTUS (RD21/0006/0024, RD21/0006/0007 and RD21/0006/0015).