Abstract :

Stroke is a highly morbid entity and it can be fatal directly due to neurological damage and affecting the respiratory system or can add to over all morbidity and mortality due to its associated complications like stroke associated pneumonia (SAP).

Objective: To determine the frequency of stroke acquired pneumonia in ICU patients.

Study Design: Descriptive case series.

Settings: Department of Medicine, THQ Hospital, Sargodha.

Period: Six months from October, 2020 to April, 2021

Material & Methods: In this study, the cases of either gender and age 30 to 70 years suffering from stroke within 12 hours were included. SAP was labelled on the basis of fever, cough and non homogenous opacities on chest X-ray.

Results: In the present study, 160 cases of stroke were included and out of these 82 (51.25%) were males and 78 (48.75%) females. The mean age of the subjects was 54.24±7.15 years and mean duration of stroke was 7.05±2.54 hours. There were 35 (21.88%) cases that had DM, 28 (17.50%) had HTN and 30 (18.75%) of cases had history of smoking. Stroke acquired pneumonia (SAP) was seen in 20 (12.50%) of the cases. SAP was seen in 12 (15.38%) female cases as compared to 8 (9.75%) males with p= 0.34. SAP was more seen in cases with DM where this was observed in 7 (20%) of the cases as compared to 13 (10.4%) with no DM with p= 0.15. SAP was seen in 5 (17.85%) cases with HTN and 4 (13.33%) cases with history of smoking with p values of 0.35 and 1.0 respectively. SAP was seen in 15 (14.42%) cases with duration of stroke 6-12 hours in contrast to 5 (8.92%) cases with duration less than this with p= 0.45.

Conclusion: Stroke acquired pneumonia is not uncommon and is seen in more than 1 out of every 10 cases and it is more seen in females and those with history of DM, HTN and duration of stroke 6 to 12 hours; though none of this variable was found statistically significant.

---

Keywords :

DM, HTN, SAP, Smoking

---

References :

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; 29:447.
2. Ingeman A, Andersen G, Hundborg HH, et al. In-hospital medical complications, length of stay, and mortality among stroke unit patients. Stroke 2011; 42:3214.
3. Kim BR, Lee J, Sohn MK, et al. Risk Factors and Functional Impact of Medical Complications in Stroke. Ann Rehabil Med 2017; 41:753.
4. Sellars C, Bowie L, Bagg J, et al. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke 2007; 38:2284.
5. Herzig SJ, Doughty C, Lahoti S, et al. Acid-suppressive medication use in acute stroke and hospital-acquired pneumonia. Ann Neurol 2014; 76:712.

6. Anand N, Kollef MH. The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP.SeminRespirCrit Care Med. 2009 Feb. 30(1):3-9. [Medline].
7. El Solh AA. Nursing home-acquired pneumonia.SeminRespirCrit Care Med. 2009 Feb. 30(1):16-25. [Medline].
8. Kuti JL, Shore E, Palter M, Nicolau DP. Tackling empirical antibiotic therapy for ventilator-associated pneumonia in your ICU: guidance for implementing the guidelines.SeminRespirCrit Care Med. 2009 Feb. 30(1):102-15. [Medline].
9. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Executive Summary: Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.Clin Infect Dis. 2016 Sep 1. 63 (5):575-82. [Medline].
10. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis.Clin Infect Dis. 2014 Feb. 58 (3):330-9. [Medline].
11. Kung HC, Hoyert DL, Xu JQ, Murphy SL, and the Division of Vital Statistics. Deaths: final data for 2005. National Vital Statistics Reports. Hyattsville, Md: National Center for Health Statistics April 2008: 56(10). http://www.cdc.gov. Available athttp://bit.ly/i3ATH5. Accessed: January 13, 2011.
12. Cillóniz C, Ewig S, Polverino E, Marcos MA, Esquinas C, Gabarrús A, et al. Microbial aetiology of community-acquired pneumonia and its relation to severity.Thorax. 2011 Apr. 66(4):340-6. [Medline].
13. Fang WF, Yang KY, Wu CL, Yu CJ, Chen CW, Tu CY, et al. Application and comparison of scoring indices to predict outcomes in patients with healthcare-associated pneumonia.Crit Care. 2011 Jan 19. 15(1):R32. [Medline].
14. Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.Thorax. 2003 May. 58(5):377-82. [Medline].
15. Sligl WI, Majumdar SR, Marrie TJ. Triaging severe pneumonia: what is the “score” on prediction rules?.Crit Care Med. 2009 Dec. 37(12):3166-8. [Medline].
16. Phua J, See KC, Chan YH, Widjaja LS, Aung NW, Ngerng WJ, et al. Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia.Thorax. 2009 Jul. 64(7):598-603. [Medline].
17. Bloos F, Marshall JC, Dellinger RP, et al. Multinational, observational study of procalcitonin in ICU patients with pneumonia requiring mechanical ventilation: a multicenter observational study.Crit Care. 2011 Mar 7. 15(2):R88. [Medline].
18. El-Solh AA, Alhajhusain A, AbouJaoude P, Drinka P. Validity of severity scores in hospitalized patients with nursing home-acquired pneumonia.Chest. 2010 Dec. 138(6):1371-6. [Medline].
19. España PP, Capelastegui A, Gorordo I, Esteban C, Oribe M, Ortega M, et al. Development and validation of a clinical prediction rule for severe community-acquired pneumonia.Am J RespirCrit Care Med. 2006 Dec 1. 174(11):1249-56. [Medline].
20. Rello J, Rodriguez A, Lisboa T, Gallego M, Lujan M, Wunderink R. PIRO score for community-acquired pneumonia: a new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia.Crit Care Med. 2009 Feb. 37(2):456-62. [Medline].
21. Charles PG, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R, et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia.Clin Infect Dis. 2008 Aug 1. 47(3):375-84. [Medline].
22. Light RW. Clinical practice. Pleural effusion.N Engl J Med. 2002 Jun 20. 346 (25):1971-7. [Medline].
23. Bafadhel M, Clark TW, Reid C, Medina MJ, Batham S, Barer MR, et al. Procalcitonin and C reactive protein in hospitalised adult patients with community acquired pneumonia, exacerbation of asthma and chronic obstructive pulmonary disease.Chest. 2010 Oct 28. [Medline].
24. Ketai L, Jordan K, Marom EM. Imaging infection.Clin Chest Med. 2008 Mar. 29(1):77-105, vi. [Medline].
25. Kamal AK, Itrat A, Murtaza M, Khan M, Rasheed A, Ali A. The burden of stroke and transient ischemic attack in Pakistan: a community-based prevalence study. BMC Neurol2009;9:58
26. Farooq MU, Majid A, Reeves MJ, Birbeck GL. The epidemiology of stroke in Pakistan: past, present, and future. Int J Stroke 2009;4:381-9.
27. Taj F, Zahid R, Syeda UE, Murtaza M, Ahmed S, Kamal AK. Risk factors of stroke in Pakistan: a dedicated stroke clinic experience. Can J NeurolSci2010;37:252-7.
28. Koennecke HC, Belz W, Berfelde D. Factors influencing in-hospital mortality and morbidity in patients treated on a stroke unit. Neurology 2011;77:965-972.
29. Ingeman A, Andersen G, Hundborg HH. In-hospital medical complications, length of stay, and mortality among stroke unit patients. Stroke 2011;42:3214.
30. Hannawi B, Rao CPV, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis. 2013;35(5):430-43.
31. Teh WH, Smith CJ, Barlas RS, Wood AD, Bettencourt-Silva JH, Clark AB, et al. Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome. ActaNeurol Scand.12956.
32. Attar H, Beilman C, Sila C. Stroke associated pneumonia; the university hospital-Cleveland Medical Center experience. Neurology. 2017;88(16):301.
33. Sari IM, Seortidewi L, Yokota C, Kikuno M, Koga M, Toyoda K. Comparison of characteristics of stroke-associated pneumonia in stroke care units in Indonesia and Japan. J Stroke Cereberovasc Dis. 2017;26(2):280-85.
34. Adrees M, Subhanullah, Rasool S, Ahmad N. Frequency of Stroke Associated Pneumonia in Stroke Patients. APMC 2017;11(2):154-157.
35. Vermeij FH, Scholte op Reimer WJ, de Man P. Stroke-associated infection is an independent risk factor for poor outcome after acute ischemic stroke: data from the Netherlands Stroke Survey. Cerebrovasc Dis 2009;27:465–71.
36. Roger VL, Go AS, Lloyd-Jones DM. Heart disease and stroke statistics – 2012 update: a report from the American Heart Association. Circulation 2012;125:e2–e220.