How Is Pneumonia Diagnosed in Clinical Stroke Research?

Kishore, Amit K.; Vail, Andy; Chamorro, Ángel; Garau, Javier; Hopkins, Stephen J.; Napoli, Mario Di; Kalra, Lalit; Langhorne, Peter; Montaner, Joan; Roffe, Christine; Rudd, Anthony; Tyrrell, Pippa J.; Beek, Diederik van de; Woodhead, Mark; Meisel, Andreas; Smith, Craig J.

doi:10.1161/strokeaha.114.007843

Cited by 136 publications

(137 citation statements)

References 81 publications

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“…18 The rate of PSP diagnosis is dependent on the diagnostic criteria used. 19 Physicians are influenced by stroke severity and poor expectation of outcome in diagnosing pneumonia 20 ; it is likely that the presence of NGT further increases this clinical bias. This study applied an objective, criteria-based algorithm blindly to the whole dataset to diagnose PSP, which not only minimized the likelihood of false-positive diagnosis but also reduced bias from PSP diagnoses that may have been missed clinically.…”

Section: Resultsmentioning

confidence: 99%

Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

Kalra

Hodsoll²,

Irshad

et al. 2016

Neurology

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Objective: To investigate whether nasogastric tubes (NGTs) increase poststroke pneumonia (PSP), mortality, or poor outcomes in nil-by-mouth acute stroke patients.Methods: This study analyzed prespecified outcomes of PSP at 14 days and mortality and function measured by the modified Rankin Scale at 90 days in 1,217 nil-by-mouth stroke patients at #48 hours of symptom onset in a multicenter randomized controlled trial of preventive antibiotics between April 21, 2008, and May 17, 2014. Generalized mixed models adjusted for age, comorbidities, stroke type and severity, and quality of care were used. No patients were lost to follow-up at 14 days, and 36 (3%) were lost at 90 days. Conclusions: Early NGT does not increase PSP incidence, mortality, or poor functional outcomes and can be used safely in acute stroke patients. Neurology ® 2016;87:1352-1359 GLOSSARY CI 5 confidence interval; mRS 5 modified Rankin Scale; NGT 5 nasogastric tube; NIHSS 5 NIH Stroke Scale; OR 5 odds ratio; PSP 5 poststroke pneumonia; STROKE-INF 5 Prophylactic antibiotics for reducing pneumonia in acute stroke patients with dysphagia study. ResultsPoststroke pneumonia (PSP) is associated with a third of early deaths and a fifth of poor outcomes in stroke.1,2 Dysphagia is present in 51% to 78% of stroke patients and is often managed with nasogastric tubes (NGTs) for nutrition and hydration.3 Dysphagia increases the risk of PSP from 2% to 8% to 16% to 19%, 4,5 which may be increased further to 33% to 70% by NGT placement.6-8 Because supportive pharmacological or antimicrobial interventions do not appear to prevent PSP, it remains a major clinical challenge in nil-by-mouth patients, even on stroke units. [9][10][11] Evidence that NGT placement increases PSP incidence remains equivocal; observational studies suggesting this association are limited by heterogeneity in patients, settings, and diagnostic criteria for PSP. [6][7][8] It is possible that PSP and higher mortality are influenced by stroke severity rather than by NGT placement.12,13 Although preventive antibiotics did not reduce PSP in unselected stroke patients, 10,11 they may be effective in patients with NGT who have greater gastric reflux and aspiration caused by NGT-induced pharyngeal and lower esophageal sphincter dysfunction.

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Section: Resultsmentioning

confidence: 99%

Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

Kalra

Hodsoll²,

Irshad

et al. 2016

Neurology

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“…Although we relied on previously validated codes for ICH and for complications, we cannot exclude potential inaccuracies because of coding errors. There is great variability in the accuracy of International Classification of Disease, 9th Revision codes for medical complications and in how clinicians actually diagnose pneumonia, 19 sepsis, and other complications. Our study of trends in complications is based on the implicit assumption that coding practices remained unchanged over time.…”

Section: Discussionmentioning

confidence: 99%

Ten-Year Temporal Trends in Medical Complications After Acute Intracerebral Hemorrhage in the United States

Otite

Khandelwal

Malik

et al. 2017

Stroke

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Background and Purpose-Data on medical complications after intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, acute renal failure (ARF), and acute myocardial infarction after ICH in the United States. Methods-A total of 575 211 adult ICH cases were identified from the 2004 to 2013 Nationwide Inpatient Sample. Weighted complication risks were computed by sex and mechanical ventilation status. Multivariate models were used to evaluate trends in complications and assess their association with in-hospital mortality, cost, and length of stay. Results-Overall risks of urinary tract infection, pneumonia, sepsis, DVT, pulmonary embolism, ARF, and acute myocardial infarction after ICH were 14.8%, 7.8%, 4.1%, 2.7%, 0.7%, 8.2%, and 2.0%, respectively, but risk differed by sex and mechanical ventilation status. From 2004 to 2013, odds of DVT and ARF increased, whereas odds of pneumonia, sepsis, and mortality declined over time. All complications were associated with >2.5-day increase in length of stay and >$8000 increase in cost. ARF and acute myocardial infarction were associated with increased mortality in all patients; sepsis and pneumonia were associated with increased mortality only in nonmechanical ventilation patients, whereas urinary tract infection and DVT were associated with reduced mortality in all patients. Conclusions-Despite significant mortality reduction, ARF and DVT risk after ICH have increased, whereas odds of sepsis and pneumonia have declined over the last decade. All complications were associated with increased cost and length of stay, but their associations with mortality were variable, likely due in part to survival bias. Innovative strategies are needed to prevent ICH-associated medical complications.

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“…It is one of the most common post-stroke infections, affecting 14% of patients [2], and is associated with an increased risk of hospital mortality [3], prolonged hospital stay [4] and associated healthcare costs [5]. The timing of SAP reflects the complex relationship between infection and inflammatory responses, which may precede and develop post stroke.…”

Section: Introductionmentioning

confidence: 99%

Impact of Dysphagia Assessment and Management on Risk of Stroke-Associated Pneumonia: A Systematic Review

et al. 2018

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Background: Patients with dysphagia are at an increased risk of stroke-associated pneumonia. There is wide variation in the way patients are screened and assessed during the acute phase. The aim of this review was to identify the methods of assessment and management in acute stroke that influence the risk of stroke-associated pneumonia. Studies of stroke patients that reported dysphagia screening, assessment or management and occurrence of pneumonia during acute phase stroke were screened for inclusion after electronic searches of multiple databases from inception to November 2016. The primary outcome was association with stroke-associated pneumonia. Summary: Twelve studies of 87,824 patients were included. The type of dysphagia screening protocol varied widely across and within studies. There was limited information on what comprised a specialist swallow assessment and alternative feeding was the only management strategy, which was reported for association with stroke-associated pneumonia. Use of a formal screening protocol and early dysphagia screening (EDS) and assessment by a speech and language pathologist (SLP) were associated with a reduced risk of stroke-associated pneumonia. There was marked heterogeneity between the included studies, which precluded meta-analysis. Key Messages: There is variation in the assessment and management of dysphagia in acute stroke. There is increasing evidence that EDS and specialist swallow assessment by an SLP may reduce the odds of stroke-associated pneumonia. There is the potential for other factors to influence the incidence of stroke-associated pneumonia during the acute phase.

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How Is Pneumonia Diagnosed in Clinical Stroke Research?

Cited by 136 publications

References 81 publications

Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients

Ten-Year Temporal Trends in Medical Complications After Acute Intracerebral Hemorrhage in the United States

Impact of Dysphagia Assessment and Management on Risk of Stroke-Associated Pneumonia: A Systematic Review

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