Mark Sabra, MD  

Vermeij J-D, Westendorp WF, Dippel DWJ, van de Beek D, Nederkoorn PJ. Antibiotic Therapy for Preventing Infections in People With Acute Stroke. Stroke. 2018

Infections are common complications in acute stroke patients, whether ischemic or hemorrhagic infarcts. Infections in the hospital setting have been associated with worse outcomes in stroke patients from a morbidity/mortality standpoint. The two most common infections that were studied were urinary tract infections and pneumonia. This publication was updating the completion of a meta-analysis that started in 2012.

Results were obtained by meta-analysis of databases, trial registers, references and randomized controlled trials. Of the 8 trials that were chosen, there were 4488 patients total with 2230 receiving preventive antibiotics vs. 2258 not receiving antibiotics.

Findings of the analysis showed that there was no change in mortality or functional outcome in those receiving preventive antibiotics versus those without. However, there was a significant decrease in infection rates with those who did get preventive antibiotics in urinary tract infections but not for pneumonia.

It seems as though preventive antibiotics should be included in post-stroke care in selected patients, especially those with urinary tract infections. The infectious agents commonly found in UTI may be more easily covered with antibiotics and less prone to resistance compared to pneumonia. Another point to consider is that UTIs are easily diagnosed with a simple urine analysis while diagnosis of pneumonia is based on an individual radiologist read and quality of image. Other diagnosis of pneumonitis on imaging may be confused with pneumonia, which would make antibiotics ineffective. Management is based on hospital protocol and differs among each facility. This discrepancy would lead to different antibiotics used and possibly poor coverage.

Further studies should be conducted to evaluate how the diagnosis of pneumonia is made and also what antibiotics are used in management of pneumonia in post-stroke patients. Patients with underlying pulmonary issues may be more prone to a worse outcome from pneumonia versus those without.

Functional outcome and mortality after stroke are multifactorial. While infections can play a role in these two entities, further research should be conducted to find other common causes that lead to decreased functional outcome and mortality outside of infection. This may include quality of the rehab facility, undiagnosed depression and severity of infarct.