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(Stroke. 2006;37:461.)
© 2006 American Heart Association, Inc.

Original Contributions

Clinical Consequences of Infection in Patients With Acute Stroke

Is It Prime Time for Further Antibiotic Trials?

Martha Vargas; Juan P. Horcajada; Victor Obach; Marina Revilla; Álvaro Cervera; Ferrán Torres; Anna M. Planas; Josep Mensa Ángel Chamorro

From the Stroke Unit, Hospital Clínic, and Institut d’ Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (A.C., V.O., M.R., A.Ch.); Infectious Diseases Unit, Hospital Clínic, Barcelona, Spain (J.P.H., M.V., J.M.); Pharmacology and Toxicology Department, Consejo Superior de Investigaciones Científicas (IIBB-CSIC), and IDIBAPS, Barcelona, Spain (A.M.P.); and Clinical Pharmacology Unit–Unitat d’Avaluació I Suport de Projectes (UASP), Hospital, Clínic, Barcelona, Spain (F.T.).

Correspondence to Ángel Chamorro, MD, PhD, Stroke Unit, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain. E-mail achamorro{at}ub.edu

	Abstract

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Background and Purpose— It is unsettled whether stroke-associated infection (SAI) is an independent prognostic factor, and a recent clinical trial failed to show that antibiotic prophylaxis prevented SAI. Contrarily, this trial suggested that antibiotic prophylaxis impaired clinical recovery. We sought to evaluate the predisposing factors and clinical consequences of SAI to gather additional insight on the need of exploring other antibiotics in acute stroke.

Methods— Between March 2001 and April 2002, 229 consecutive patients were admitted into the neurological wards within 24 hours of stroke onset. Demographics, risk factors, National Institutes of Health Stroke Scale (NIHSS) score, vital data, imaging, and laboratory findings were prospectively evaluated. SAI was treated as early as possible. Multivariate regression analyses assessed predisposing factors of SAI and the independent association between SAI and poor stroke outcome at day 7 (Rankin >2).

Results— Sixty (26%) patients developed SAI, most frequently chest infections, and within 3 days of stroke onset. Tube feeding (odds ratio [OR], 3.2; 95% CI, 1.3, 7.8) was the strongest predisposing factor of SAI. Poor outcome at hospital discharge was associated to baseline NIHSS score (OR, 10.0; 95% CI, 1.5, 100) and tube feeding (OR, 16.6; 95% CI, 2.9, 100.0), adjusted for confounders including antibiotic use. SAI was not independently associated to poor outcome (OR, 0.9; 95% CI, 0.9, 1.0).

Conclusions— SAI is a marker of the severity of stroke without an independent outcome effect when it is promptly treated. These results support current stroke guidelines that advise prompt treatment of infection and warn against antibiotic prophylaxis. Yet, these recommendations should not prevent the performance of acute stroke trials assessing the value of antibiotics with acknowledged neuroprotective properties.

Key Words: infection • outcome assessment • stroke

	Introduction

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The medical management of acute stroke includes measures aimed to prevent or treat systemic complications, such as stroke-associated infection (SAI), which could affect the course of the disease.^1,2 Although SAI stands as one of the most frequent medical problems in patients with acute stroke,^3,4 few studies^5,6 have addressed the clinical consequences of septic complications. Theoretically, SAI could be deleterious by mechanisms that include electrolytic unbalance, fever, or hypoxia.⁷ Under these conditions, neuronal survival would be impaired within the ischemic penumbra, and this would favor larger lesions, longer hospital stay, additional costs, and delayed rehabilitation. Although current data support that SAI predominate in the most disabled patients, they do not allow to reach definite conclusions whether there is an independent association between SAI and the rate of recovery after stroke.^3–6 Clarification of this issue in patients with acute stroke is determinant to recommend when and how to use antiseptic measures, including the prophylactic administration of antibiotics.

Current guidelines on acute stroke management advise against prophylactic administration of antibiotics,¹ and the only randomized clinical trial of antibiotic prophylaxis recently provided evidence-based support to this recommendation because it showed that levofloxacin was not better than placebo to prevent infections.⁸ Unexpectedly, the Early Systemic Prophylaxis of Infection After Stroke (ESPIAS) trial also suggested that this approach might impair clinical recovery, although the trial did not exclude that other antibiotic regimens might be beneficial.⁸ In light of these findings, the value of prophylactic regimens in acute stroke seems doubtful, although further testing would be justified if it were convincingly shown that stroke recovery is impaired regardless of successful control of infections. In this study, we sought to assess the independent association between SAI and clinical outcome in stroke patients who received adequate antibiotic therapy as soon as infection was suspected. These patients were part of a prospective observational study designed in preparation of the ESPIAS study reported recently.⁸

	Methods

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Study Population
From March 2001 through April 2002, we performed a prospective evaluation of all incident infections occurring in patients with acute stroke admitted consecutively to the Neurology Service within 24 hours of symptom onset. Patients with transient ischemic attack, admission temperature 37.5°C, or patients who required admission into an intensive care unit or mechanical intubation were not included in the study. The study was approved by the local ethical committee, and stroke neurologists, infectious disease specialists, and research nurses worked in close collaboration to warrant a harmonized application of diagnostic and therapeutic measures. Patients had a brain computed tomography scan or brain MRI before admission, as well as the diagnostic workup aimed to identify the cause of ischemic or hemorrhagic strokes. Stroke syndromes were classified as lacunar and nonlacunar, the former including pure motor hemiparesis, sensorimotor stroke, ataxic hemiparesis, pure sensory syndrome, and dysarthria clumsy hand syndrome. Daily neurological exams were performed using the National Institutes of Health Stroke Scale (NIHSS), and particular attention was given to the occurrence of fever, vomiting, urinary retention, or swallowing abnormalities that might favor infection. Swallowing function was assessed at the bedside with the water swallowing test,⁹ and in patients with abnormal tests, a nasogastric tube was immediately placed to initiate feeding. Axillary temperature was assessed at least every 8 hours, and oxygenation, heart rate, blood pressure, respiratory function, serum glucose, and leukocyte count were frequently recorded in all patients. Arterial hypertension, diabetes, active smoking, alcohol intake, hypercholesterolemia, and coronary heart disease were assessed following conventional definitions. Additional historical data included chronic pulmonary obstructive disease, infections in the previous 3 months, previous strokes, cancer, and chronic renal disease.

Fever was defined as axillary temperature 37.5°C in 2 separate determinations or 37.8°C in 1 single determination. Nonseptic fever was described as axillary temperature 37.5°C without symptoms or signs of infection and blood leukocyte count <11.000 cell/mL or >4.000 cell/mL. Acute bronchial infection included fever, bronchial purulent secretions, blood leukocyte count >11.000 cell/mL or <4.000 cell/mL, and normal chest x-ray films. Pneumonia was described as pulmonary infiltrates in chest radiograph, fever, respiratory symptoms (cough, dyspnea, or pleuritic pain), and blood leukocyte count >11.000 cell/mL or <4.000 cell/mL. Aspiration was defined as acute bronchial infection or pneumonia 24 to 48 hours after a witnessed vomit. Urinary tract infection was defined as low urinary tract symptoms with a positive urine culture for an uropathogen (>10⁵ colony-forming units [cfu]/mm³) or fever with a positive urine culture for an uropathogen in absence of other infectious source. Bacteremia included a blood culture positive for a pathogen; if coagulase-negative staphylococcae were isolated from blood, confirmation was required in a second positive blood culture with the same antibiogram. Bacteremia attributable to intravenous catheter required the isolation of the same pathogen from blood and the catheter tip (>15 cfu) in the absence of other infectious source. Catheter-related phlebitis was described as inflammatory symptoms and signs at the insertion point or subcutaneous trajectory of peripheral or central intravenous catheter. SAI was defined as infections diagnosed during the first 7 days of stroke onset to limit the confounding effect of time at risk. Infections were treated with antibiotics as judged most appropriate by specialists on infectious diseases, and antipyretics were administered if body temperature was >37.5°C. Outcome was assessed at day 7 and defined as poor if the modified Rankin scale (MRS) score was >2. Patients could be discharged before day 7 only when the neurological state remained stable for 48 hours.

Microbiologic Methods
Blood cultures were performed in the presence of fever, and urine cultures were obtained in the presence of urinary tract symptoms, or if fever was not accompanied by any focal symptoms. Samples were obtained by spontaneous micturation or from previously inserted urinary catheters. Urine culture was considered positive when 105 cfu/mL of an uropathogen was isolated. Respiratory samples were obtained in the presence of respiratory tract symptoms, and sputum samples were obtained in collaborative patients. Tracheal aspirate was obtained in patients with abundant respiratory secretions and low level of consciousness. Samples were grown on McConkey agar at 37°C and cystine lactose electrolyte deficient agar for quantification during 48 hours. Identification of isolated microorganisms was performed by standard methods.¹⁰ Antibiotic susceptibility testing was performed by the E-test method (AB Biodisk) and Kirby Bauer method following the instructions of the manufacturer, according to the National Committee for Clinical Laboratory Standards recommendations. Blood cultures were placed into 2 blood culture bottles and tested daily by means of an infrared ray (Bactec 9240) system during 5 days. Significant bacteremia was considered when a pathogenic microorganism was isolated in 1 blood culture.

Statistical Analysis
Dichotomous and categorical data were compared by use of Fisher exact test or the ² as appropriate. Differences in continuous variables were assessed with Student’s test if normally distributed or nonparametric tests otherwise. Logistic regression modeling was used to assess statistically significant predictors of SAI during the acute phase of stroke and poor outcome at discharge. Variables with a P value <0.10 on univariate testing were selected in these models. When necessary, collinearity was minimized generating interaction terms. Antibiotic use was studied as a whole group without the analysis of individual drugs. All tests of significance were 2-tailed and at 0.05 level.

	Results

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SAI: Incidence, Topography, and Pathogens
A total of 295 stroke patients were admitted during the study period, although patients with a delay to admission of >24 hours (n=58) or with signs or symptoms of ongoing infection at first examination (n=8) were excluded. Thus, 229 patients assessed at a median delay of 4.7 (interquartile range [IQR], 2.5, 10.2) hours from stroke onset took part in the study. Median time to hospital discharge was 9 (IQR, 5, 13) days. Sixty (26%) patients developed SAI, 11 (5%) patients had bacteremia attributable to an intravenous catheter, and 22 (10%) developed nonseptic fever. Forty-five (75%) patients were diagnosed with SAI within the first 3 days of admission. Antibiotics were administered to 93 (41%) patients within 7 days of stroke onset. Antibiotics included amoxicillin (n=48), levofloxacin (n=35), cephalosporins (n=5), tazobactam-piperacillin (n=3), and vancomycin (n=2). The topography of infections and the responsible micro-organisms were as described in Table 1. The yield of positive cultures was 11% for blood samples, 31% for urine samples, and 47% for tracheal aspirate samples, respectively.

View this table: [in this window] [in a new window]   TABLE 1. Topography of Infection and Isolated Micro-Organisms

Risk Factors of Infection
SAI was associated in univariate analysis to older age, female gender, higher median NIHSS on admission, vomiting at stroke onset, nonlacunar stroke, and tube feeding, as shown in Table 2. Using logistic regression analysis, tube feeding was the strongest and sole independent predictor of SAI (odds ratio [OR], 3.2; 95% CI, 1.3, 7.8; P<0.01).

View this table: [in this window] [in a new window]   TABLE 2. Univariate Predictors of Early Infection in 229 Stroke Patients

Clinical Outcome
At day 7, 72 (31%) patients had an MRS score of 0 to 2, and 157 (69%) patients had an MRS score of >2, including 26 (11%) patients who died because of stroke (n=16), sepsis (n=5), or cardiovascular diseases (n=5). As shown in Table 3, poor outcome (MRS >2) was associated in univariate analysis to age, gender, admission delay, smoking, baseline NIHSS, stroke syndrome, baseline temperature, tube feeding, SAI, and antibiotic use. In a logistic regression model, only baseline NIHSS score (OR, 10.0; 95% CI, 1.5, 100) and tube feeding (OR, 16.6; 95% CI, 2.9, 100.0) remained associated to poor outcome. Contrarily, SAI (OR, 0.9; 95% CI, 0.9, 1.0) or the interaction term SAI*antibiotic use (OR, 0.8; 95% CI, 0.3, 3.0) did not enter in the logistic regression model of stroke outcome.

View this table: [in this window] [in a new window]   TABLE 3. Clinical Outcome at Discharge

	Discussion

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In this prospective cohort, 26% of the patients developed SAI within the first 7 days of stroke onset, and 10% of additional patients developed nonseptic fever (37.5°C), confirming that infections and hyperthermia are a sizable problem not only in intensive care settings¹¹ and general wards¹² but also in neurological wards. The main finding of the study was that infections diagnosed and treated with antibiotics within 7 days of stroke onset did not contribute significantly to the likelihood of poor outcome at day 7. Yet, the study confirmed that SAI was directly related to the initial severity of the stroke,^12,13 occurred more frequently within the first 3 days of stroke,^14,15 and in patients fed by nasogastric tube.⁶ Indeed, 77% of the patients fed by nasogastric tube developed an infection within 7 days of stroke onset compared with 28% of orally fed patients. These results give credit to the notion that feeding tubes offer no protection from colonized oral secretions in patients with dysphagia.^16–18 However, because tube feeding and stroke severity were collinear, contribution of additional factors cannot be excluded, such as older age, immobility, impaired pulmonary function, immunosuppression, and malnutrition.^19–21 Moreover, the independent association between poor outcome and tube feeding was mostly explained by the greater severity of stroke at baseline in patients who required tube feeding. Unlike the predominance of urinary tract infections, which are more frequent during the chronic phase of stroke,¹² chest infections predominated during the earliest phase of stroke. However, unlike series that included mechanical ventilated subjects,¹¹ the predominant chest complications were acute bronchial infections rather than pneumonias. Overall, one fourth of the infections yielded positive cultures, particularly in tracheal aspirate samples, and revealed micro-organisms that are commonly acquired in the community.

In contrast with previous tertiary analysis,⁵ series of mechanically ventilated patients,¹¹ and studies that disregarded the effect of confounding factors,¹² SAI did not emerge in our study as an independent prognostic factor. Outcome assessment in the study did not evaluate long-lasting effects. However, the study accounted prospectively for the effect of decisive prognostic factors, such as age, baseline stroke severity, stroke subtype, delay to admission, tube feeding, and body temperature. Moreover, strict operational criteria were set at the outset of the study to minimize underreporting or misclassification of infectious events.⁵ The administration of antibiotics was not randomized, but their effect was accounted for in the prediction models. However, to avoid the creation of small subgroups, the effect of individual antibiotics was not measured. Although the strict control of fever might have also lessened the consequences of infection,²² a small randomized controlled trial of early antipyretic therapy recently showed only modest benefits in acute stroke.²³ Therefore, the most likely explanation for the lack of independent association that we found between SAI and poor outcome was the prompt initiation of an antibiotic therapy. Admission temperature did not emerge as an independent prognostic factor in our study, most likely because patients with elevated temperature at stroke onset (37.5°C) were not included.

Empirically, current stroke therapy guidelines recommend to watch carefully for the appearance of infection and to treat rapidly with antibiotics all emergent infections.^1,2 Our results showing that expeditiously treated infections were not detrimental are in support of these guidelines. Antibiotics have also been given prophylactically to patients with acute stroke.⁸ The rationale of such approach was that infections could decrease the degree of recovery,⁵ whereas early preventive measures might avoid it. However, antibiotics given during the early phase of brain ischemia could do more than kill bacteria because the ESPIAS trial showed less recovery in patients treated with levofloxacin than placebo,⁸ a finding that was attributed to the effects of this drug on -aminobutyric acid and glutamate neurotransmission.^24,25 Notwithstanding, certain antibiotics might theoretically provide clinical benefits in acute stroke in relation to previously unrecognized effects on the central nervous system. Thus, moxifloxacin²⁶ and minocycline²⁷ have demonstrated marked neuroprotective effects after focal brain ischemia in mice and rats. Indeed, an ongoing clinical trial is evaluating the effect of moxifloxacin in patients with acute stroke. Several ß-lactam antibiotics have also shown protection against the dysfunctional effects of the neurotransmitter glutamate by activating the expression of a glutamate transporter in in vitro models of ischemic injury.²⁸ Given the relevance of glutamate in stroke, ß-lactam antibiotics are a promising option for future acute stroke trials in patients with or without SAI.

In summary, the study shows that SAI is a very common complication after stroke that does not contribute independently to the likelihood of poorer outcome. These results support current stroke guidelines that advise prompt treatment of infection and reinforce the advise against antibiotic prophylaxis in this clinical condition. However, these recommendations should not be an obstacle to the performance of acute stroke trials that assess the outcome effects of antibiotics with acknowledged neuroprotective properties.

Received September 12, 2005; revision received October 13, 2005; accepted November 2, 2005.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Hacke W, Kaste M, Bogousslavsky J, Brainin M, Chamorro A, Lees K, Leys D, Kwiecinski H, Toni P, Langhorne P, Diener C, Hennerici M, Ferro J, Sivenius J, Gunnar N, Bath P, Olsen TS, Gugging M; European Stroke Initiative Executive Committee and the EUSI Writing Committee. European stroke initiative recommendations for stroke management-update 2003. Cerebrovasc Dis. 2003; 16: 311–337.[CrossRef][Medline] [Order article via Infotrieve]
2. Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ; Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003; 34: 1056–1083.[Free Full Text]
3. Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke. 1996; 27: 415–420.[Abstract/Free Full Text]
4. Weimar C, Roth MP, Zillessen G, Glahn J, Wimmer ML, Busse O, Haberl RL, Diener HC; German Stroke Date Bank Collaborators. Complications following acute ischemic stroke. Eur Neurol. 2002; 48: 133–140.[Medline] [Order article via Infotrieve]
5. Aslanyan S, Weir CJ, Diener HC, Kaste M, Lees KR; GAIN International Steering Committee and Investigators. Pneumonia and urinary tract infection after acute ischemic stroke: a tertiary analysis of the GAIN Internatinal Trial. Eur J Neurol. 2004; 11: 49–53.[CrossRef][Medline] [Order article via Infotrieve]
6. Dziewas R, Ritter M, Schilling M, Konrad C, Oelenberg S, Nabavi DG, Stögbaver F, Ringelstein EB, Lüdermann P. Pneumonia in acute stroke patients fed by nasogastric tube. J Neurol Neurosurg Psychiatry. 2004; 75: 852–856.[Abstract/Free Full Text]
7. Ginsberg MD, Busto R. Combating hyperthermia in acute stroke: a significant clinical concern. Stroke. 1998; 29: 529–534.[Abstract/Free Full Text]
8. Chamorro A, Horcajada JP, Obach V, Vargas M, Revilla M, Torres F, Cervera A, Planas AM, Mensa J. The Early Systemic Prophylaxis of Infection After Stroke study: a randomized clinical trial. Stroke. 2005; 36: 1495–1500.[Abstract/Free Full Text]
9. DePippo K, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following acute stroke. Arch Neurol. 1992; 49: 1259–1261.[Abstract]
10. Balows A, Hausler WJ Jr, Herrmann KL, Isenberg JD, Shadomy HJ, eds. Manual of Clinical Microbiology. Washington, DC: American Society of Microbiology; 1991.
11. Hilker R, Petter C, Findeisen N, Sobesky J, Jacobs A, Neveling M, Heiss WD. Nosocomial pneumonia after acute stroke. Implications for neurological intensive care medicine. Stroke. 2003; 34: 975–981.[Abstract/Free Full Text]
12. Langhorne P, Stott DJ, Robertson L, MacDonald J, Jones L, McAlpine C, Dick F, Taylor GS, Murray G. Medical complications after stroke: a multicenter study. Stroke. 2000; 31: 1223–1229.[Abstract/Free Full Text]
13. Johnston KC, Li JY, Lyden PD, Hanson SK, Feasby TE, Adams RJ, Faught RE, Haley EC. Medical and neurological complications of ischemic stroke: experience from the RANTTAS trial. Stroke. 1998; 29: 447–453.[Abstract/Free Full Text]
14. Grau AJ, Buggle F, Schnitzler P, Spiel M, Lichy C, Hacke W. Fever and infection early after ischemic stroke. J Neurol Sci. 1999; 171: 115–120.[CrossRef][Medline] [Order article via Infotrieve]
15. Castillo J, Dávalos A, Marrugat J, Noya M. Timing for fever-related brain damage in acute ischemic stroke. Stroke. 1998; 29: 2455–2460.[Abstract/Free Full Text]
16. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Eng J Med. 2001; 344: 665–671.[Free Full Text]
17. Schmidt J, Holas M, Halvorson K, Reding M. Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke. Dysphagia. 1994; 9: 7–11.[Medline] [Order article via Infotrieve]
18. Nakagawa T, Sekizawa K, Nakajoh K, Tanji H, Arai H, Sasaki H. Silent cerebral infarction: a potential risk for pneumonia in the elderly. J Intern Med. 2000; 247: 255–259.[CrossRef][Medline] [Order article via Infotrieve]
19. FOOD Trail Collaboration. Poor nutritional status on admission predicts poor outcomes after stroke. Observational data from the FOOD Trial. Stroke. 2003; 34: 1450–1456.[Abstract/Free Full Text]
20. Chandra RK. Graying of the immune system: can nutrient supplements improve immunity in the elderly? J Am Med Assoc. 1997; 277: 1398–1399.[CrossRef][Medline] [Order article via Infotrieve]
21. Weimar C, Ziegler A, Köning IR, Diener HC; German Stroke Study Collaborators. Predicting functional outcome and survival after acute ischemic stroke. J Neurol. 2002; 249: 888–895.[CrossRef][Medline] [Order article via Infotrieve]
22. Reith J, Jorgensen HS, Pedersen PIVI, Nakayama H, Raaschou HO, Jeppesen LL, Olsen TS. Body temperature in acute stroke: relation to stroke severity, infarct size, mortality, and outcome. Lancet. 1996; 347: 422–425.[CrossRef][Medline] [Order article via Infotrieve]
23. Koennecke HC, Leistner S. Prophylactic antipyretic treatment with acetaminophen in acute ischemic stroke: a pilot study. Neurology. 2001; 57: 2301–2303.[Abstract/Free Full Text]
24. Dodd PR, Davies LP, Watson WE, Nielsen B, Dyer JA, Wong LS, Johnston GA. Neurochemical studies on quinolone antibiotics: effects on glutamate, GABA and adenosine systems in mammalian CNS. Pharmacol Toxicol. 1989; 64: 404–411.[Medline] [Order article via Infotrieve]
25. Schmuck G, Schurmann A, Schluter G. Determination of the excitatory potencies of fluoroquinolones in the central nervous system by an in vitro model. Antimicrob Agents Chemother. 1998; 42: 1831–1836.[Abstract/Free Full Text]
26. Meisel C, Prass K, Braun J, Braun J, Halle E, Wolf T, Ruscher K, Victorov IV, Priller J, Dirnagl U, Volk HD, Meisel A. Preventive antibacterial treatment improves the general medical and neurological outcome in a mouse model of stroke. Stroke. 2004; 35: 2–6.[Abstract/Free Full Text]
27. Xu L, Fagan SC, Waller JL, Edwards D, Borlongan CV, Zheng J, Hill WD, Feuerstein G, Hess DC. Low dose intravenous minocycline is neuroprotective after middle cerebral artery occlusion-reperfusion in rats. BMC Neurology. 2004; 4: 7.[Medline] [Order article via Infotrieve]
28. Rothstein JD, Patel S, Regan MR, Haenggell C, Huang YH, Bergles DE, Jin L, Hoberg MD, Vidensky S, Cheng DS, Toan SV, Bruijn LI, Su Z, Gupta PJ, Fisher PB. ß-lactam antibiotics offer neuroprotection by increasing glutamate transporter expression. Nature. 2005; 433: 73–77.[CrossRef][Medline] [Order article via Infotrieve]

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This Article Abstract Full Text (PDF) All Versions of this Article: 37/2/461    most recent 01.STR.0000199138.73365.b3v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vargas, M. Articles by Chamorro, A. Search for Related Content PubMed PubMed Citation Articles by Vargas, M. Articles by Chamorro, A. Pubmed/NCBI databases Medline Plus Health Information Antibiotics Stroke