Published Online
on December 29, 2005

A more recent version of this article appeared on February 1, 2006

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Submitted on September 12, 2005
Revised on October 13, 2005
Accepted on November 2, 2005

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; and 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.).

^* To whom correspondence should be addressed. E-mail: achamorro{at}ub.edu.

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

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