Should preventive antibiotics be used in patients with acute stroke? A systematic review and meta-analysis of randomized controlled trials

Abstract

BackgroundInfection is a common complication in acute stroke. Whether or not preventive antibiotics reduce the risk of infection or even lead to a favorable outcome and reduction of mortality after a stroke still remains equivocal. This review was performed to update the current knowledge on the effect and possible benefits of prophylactic antibiotic therapy in patients with stroke.MethodsA systematic review and meta-analysis of preventive antibiotics`effect on the incidence of infection, favorable outcome (mRS≤2) and mortality in patients with acute stroke is performed with relevant randomized controlled trials.ResultsSix studies were identified, involving 4125 participants. Compared with the control group, the treated groups were significantly less prone to suffer from early overall infections [RR = 0.52, 95%CI (0.39, 0.70), p<0.0001], early pneumonia [RR = 0.64, 95%CI (0.42, 0.96), p = 0.03] and early urinary tract infections [RR = 0.35, 95%CI (0.25, 0.48), p<0.00001]. However, there was no significant difference in overall mortality [RR = 1.07, 95%CI (0.90, 1.27), p = 0.44], early mortality [RR = 0.99, 95%CI (0.78, 1.26), p = 0.92], late mortality [RR = 1.12, 95%CI (0.94, 1.35), p = 0.21] or favorable outcome [RR = 1.00, 95%CI (0.92, 1.08), p = 0.98].ConclusionAlthough preventive antibiotic treatment did reduce the occurrence of early overall infections, early pneumonia and early urinary tract infection in patients with acute stroke, this advantage was not eventually translated to a favorable outcome and reduction in mortality. Future studies are warranted to identify any subgroup of stroke patients who might benefit from preventive antibiotic treatment.

Immunomodulatory Therapeutic Strategies in Stroke

“…In terms of post-stroke infection outcomes, the most recent systematic reviews of prophylactic antibiotic therapy suggest that this approach is not effective (Vermeij et al, 2018). Despite a meta-analysis finding that preventative antibacterial drugs reduced overall infection rates, no effect on functional outcome (modified Rankin scale) or mortality was seen (Zheng et al, 2017). Importantly, however, the pathophysiology of post-stroke infection is still poorly understood, while certain classes of antibiotics (e.g., fluoroquinolones) have known neurotoxic properties.…”

Healthcare-Associated Infections in the Neurocritical Care Unit

“…The urgent need to develop novel ways to prevent HAI persists, as they increase morbidity, mortality, and healthcare utilization with worse outcomes. Preventive antibiotics have not shown benefit and are not recommended even in subpopulations with an acute neurological disease [105]. Infectionprevention bundles and standardized care have been the cornerstone for prevention for all types of HAI.…”

Risk factors for and impact of poststroke pneumonia in patients with acute ischemic stroke

“… [4] While the prevention of PSP could mitigate mortality following stroke, pharmacological or antimicrobial interventions have hitherto been ineffective in preventing PSP, and the risk factors for PSP remain obscure. [ 9 – 14 ] Furthermore, it also remains unclear whether PSP has an impact on the prognosis and mortality at 3 months following stroke since most of the related research does not consider outcomes following discharge. A previous study reported that pneumonia following stroke is an independent risk factor for adverse outcomes after 3 months.…”