Infection after acute ischemic stroke: risk factors, biomarkers, and outcome

Katja E Wartenberg, Anett Stoll, Andreas Funk, Andreas Meyer, J Michael Schmidt, Joerg Berrouschot, Katja E Wartenberg, Anett Stoll, Andreas Funk, Andreas Meyer, J Michael Schmidt, Joerg Berrouschot

Abstract

Background. The activation of inflammatory cascades triggered by ischemic stroke may play a key role in the development of infections. Methods. Patients admitted with ischemic stroke within 24 hours were prospectively enrolled. Biomarkers of infection were measured on days 1, 3, and 5. The patients were continuously monitored for predefined infections. Results. Patients with infection were older (OR 1.06 per year, 95% CI 1.01-1.11) and had a higher National Institute of Health Stroke Scale Score (NIHSS, OR 1.21, 95% CI 1.10-1.34), localization in the insula, and higher stroke volumes on diffusion-weighted imaging. The maximum temperature on days 1 and 3, leukocytes, interleukin-6, lipopolysaccharide-binding protein on days 1, 3, and 5, C-reactive protein on days 3 and 5, and procalcitonin on day 5 were higher and HLA-DR-expression on monocytes on days 1, 3, and 5 lower in patients with infection. Age and NIHSS predicted the development of infections. Infection was an independent predictor of poor functional outcome. Conclusions. Severe stroke and increasing age were shown to be early predictors for infections after stroke.

References

    1. Hong KS, Kang DW, Koo JS, et al. Impact of neurological and medical complications on 3-month outcomes in acute ischaemic stroke. European Journal of Neurology. 2008;15(12):1324–1331.
    1. Johnston KC, Li JY, Lyden PD, et al. Medical and neurological complications of ischemic stroke: experience from the ranttas trial. Ranttas investigators. Stroke. 1998;29(2):447–453.
    1. Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW. The effect of pneumonia on mortality among patients hospitalized for acute stroke. Neurology. 2003;60(4):620–625.
    1. Langhorne P, Stott DJ, Robertson L, et al. Medical complications after stroke: a multicenter study. Stroke. 2000;31(6):1223–1229.
    1. Ovbiagele B, Hills NK, Saver JL, Johnston SC. Frequency and determinants of pneumonia and urinary tract infection during stroke hospitalization. Journal of Stroke and Cerebrovascular Diseases. 2006;15(5):209–213.
    1. Tirschwell DL, Kukull WA, Longstreth WT., Jr. Medical complications of ischemic stroke and length of hospital stay: experience in Seattle, Washington. Journal of Stroke and Cerebrovascular Diseases. 1999;8(5):336–343.
    1. Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke. 1996;27(3):415–420.
    1. Sellars C, Bowie L, Bagg J, et al. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke. 2007;38(8):2284–2291.
    1. Dirnagl U, Klehmet J, Braun JS, et al. Stroke-induced immunodepression: experimental evidence and clinical relevance. Stroke. 2007;38(2):770–773.
    1. Chamorro A, Urra X, Planas AM. Infection after acute ischemic stroke: a manifestation of brain-induced immunodepression. Stroke. 2007;38(3):1097–1103.
    1. Gonsalves MD, Sakr Y. Early identification of sepsis. Current Infectious Disease Reports. 12:329–335.
    1. Ringleb PA, Bousser MG, Ford G, et al. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular Diseases. 2008;25(5):457–507.
    1. Adams HP, Jr., Del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American heart association/American stroke association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: the american academy of neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38(5):1655–1711.
    1. Cincura C, Pontes-Neto OM, Neville IS, et al. Validation of the national institutes of health stroke scale, modified rankin scale and barthel index in Brazil: the role of cultural adaptation and structured interviewing. Cerebrovascular Diseases. 2009;27(2):119–122.
    1. Grau AJ, Buggle F, Steichen-Wiehn C, et al. Clinical and biochemical analysis in infection-associated stroke. Stroke. 1995;26(9):1520–1526.
    1. Haeusler KG, Schmidt WU, Fohring F, et al. Cellular immunodepression preceding infectious complications after acute ischemic stroke in humans. Cerebrovascular Diseases. 2008;25(1-2):50–58.
    1. Klehmet J, Harms H, Richter M, et al. Stroke-induced immunodepression and post-stroke infections: lSSessons from the preventive antibacterial therapy in stroke trial. Neuroscience. 2009;158(3):1184–1193.
    1. Prass K, Meisel C, Hoflich C, et al. Stroke-induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke t helper cell type 1-like immunostimulation. Journal of Experimental Medicine. 2003;198(5):725–736.
    1. Vogelgesang A, Grunwald U, Langner S, et al. Analysis of lymphocyte subsets in patients with stroke and their influence on infection after stroke. Stroke. 2008;39(1):237–241.
    1. Chamorro A, Amaro S, Vargas M, et al. Interleukin 10, monocytes and increased risk of early infection in ischaemic stroke. Journal of Neurology, Neurosurgery and Psychiatry. 2006;77(11):1279–1281.
    1. Hug A, Dalpke A, Wieczorek N, et al. Infarct volume is a major determiner of post-stroke immune cell function and susceptibility to infection. Stroke. 2009;40(10):3226–3232.
    1. Villar J, Perez-Mendez L, Espinosa E, et al. Serum lipopolysaccharide binding protein levels predict severity of lung injury and mortality in patients with severe sepsis. PLoS ONE. 2009;4(8, article e6818)
    1. Dieler C, Frohlich E, Bourquain H, Holle R, von Kummer R. Simple volumetry of ischemic cerebral infarction using computerized tomography.interobserver and method comparison. Rofo. 1999;171:279–282.
    1. Adams HP, Jr., Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Toast. trial of org 10172 in acute stroke treatment. . Stroke. 1993;24(1):35–41.
    1. .
    1. Schwarz SA, Sick C, Meairs S, Hennerici MG. Effects of prophylactic antibiotic therapy with mezlocillin plus sulbactam on the incidence and height of fever after severe acute ischemic stroke: the mannheim infection in stroke study (miss) Stroke. 2008;39(4):1220–1227.
    1. Harms HPK, Meisel C, Klehmet J, et al. Preventive antibacterial therapy in acute ischemic stroke: a randomized controlled trial. PLoS ONE. 2008;3, article e2158
    1. Chamorro AHJ, Obach V, Vargas M, et al. The early systemic prophylaxis of infection after stroke study: a randomized clinical trial. Stroke. 2005;36(7):1495–1500.
    1. Lampl Y, Boaz M, Gilad R, et al. Minocycline treatment in acute stroke: an open-label, evaluator-blinded study. Neurology. 2007;69(14):1404–1410.
    1. Liesz A, Hagmann S, Zschoche C, et al. The spectrum of systemic immune alterations after murine focal ischemia: immunodepression versus immunomodulation. Stroke. 2009;40(8):2849–2858.
    1. Chamorro A, Amaro S, Vargas M, et al. Catecholamines, infection, and death in acute ischemic stroke. Journal of the Neurological Sciences. 2007;252(1):29–35.
    1. Palasik WFU, Lechowicz W, Czartoryska B, Krzesiewicz M, Lugowska A. Assessment of relations between clinical outcome of ischemic stroke and activity of inflammatory processes in the acute phase based on examination of selected parameters. European Neurology. 2005;53(4):188–193.
    1. Kwan J, Hand P. Infection after acute stroke is associated with poor short-term outcome. Acta Neurologica Scandinavica. 2007;115(5):331–338.
    1. Vermeij FH, Scholte op Reimer WJ, De Man P, et al. Stroke-associated infection is an independent risk factor for poor outcome after acute ischemic stroke: data from the Netherlands stroke survey. Cerebrovascular Diseases. 2009;27(5):465–471.
    1. Heuschmann PU, Kolominsky-Rabas PL, Misselwitz B, et al. Predictors of in-hospital mortality and attributable risks of death after ischemic stroke: the German stroke registers study group. Archives of Internal Medicine. 2004;164(16):1761–1768.
    1. Hilker R, Poetter C, Findeisen N, et al. Nosocomial pneumonia after acute stroke: implications for neurological intensive care medicine. Stroke. 2003;34(4):975–981.
    1. Walter U, Knoblich R, Steinhagen V, Donat M, Benecke R, Kloth A. Predictors of pneumonia in acute stroke patients admitted to a neurological intensive care unit. Journal of Neurology. 2007;254(10):1323–1329.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir