Stroke-Associated Pneumonia Risk Score: Validity in a French Stroke Unit

doi:10.1016/j.jstrokecerebrovasdis.2016.09.015

Journal of Stroke and Cerebrovascular Diseases

Volume 26, Issue 1, January 2017, Pages 225-229

https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.09.015 Get rights and content

Background

Stroke-associated pneumonia is a leading cause of in-hospital death and post-stroke outcome. Screening patients at high risk is one of the main challenges in acute stroke units. Several screening tests have been developed, but their feasibility and validity still remain unclear.

Objective

The aim of our study was to evaluate the validity of four risk scores (Pneumonia score, A2DS2, ISAN score, and AIS-APS) in a population of ischemic stroke patients admitted in a French stroke unit.

Methods

Consecutive ischemic stroke patients admitted to a stroke unit were retrospectively analyzed. Data that allowed to retrospectively calculate the different pneumonia risk scores were recorded. Sensitivity and specificity of each score were assessed for in-hospital stroke-associated pneumonia and mortality. The qualitative and quantitative accuracy and utility of each diagnostic screening test were assessed by measuring the Youden Index and the Clinical Utility Index.

Results

Complete data were available for only 1960 patients. Pneumonia was observed in 8.6% of patients. Sensitivity and specificity were, respectively, .583 and .907 for Pneumonia score, .744 and .796 for A2DS2, and .696 and .812 for ISAN score. Data were insufficient to test AIS-APS. Stroke-associated pneumonia risk scores had an excellent negative Clinical Utility Index (.77-.87) to screen for in-hospital risk of pneumonia after acute ischemic stroke.

Conclusion

All scores might be useful and applied to screen stroke-associated pneumonia in stroke patients treated in French comprehensive stroke units.

Introduction

Post-stroke functional prognosis is related to acute stroke severity and to the occurrence of medical complications, such as pneumonia, urinary tract infections, or deep venous thrombosis, which overall are observed in one third of the patients.¹ Stroke-associated pneumonia (SAP) is one of the most frequent of these complications, between 2.3% and 28% depending on the type of medical ward, and the most disabling with a strong association with a poor functional outcome and mortality.2, 3, 4, 5 Despite significant trends in the reduction of this complication since the development of the stroke units and dedicated medical and paramedical teams,⁶ SAP remains still too frequent. Therefore, it is becoming mandatory to identify efficient screening tools in order to predict which patient will have higher risks and implement specific strategies to prevent this disorder.6, 7 To this purpose, several risk scores based on routinely available clinically available parameters have been developed in several countries, such as the A2DS2 in Germany,⁸ the Pneumonia score in Korea,⁹ the ISAN score in UK,¹⁰ and the AIS-APS in China.¹¹ To our knowledge, the feasibility and validity of these scores were not compared on an independent population.12, 13

The aims of this study were to (1) evaluate the in-hospital rate of SAP and mortality in a population of ischemic stroke patients admitted in a French comprehensive stroke center, (2) investigate the feasibility to retrospectively evaluate four risk scores based on data recorded in the stroke unit, and (3) compare the validity of these scores.

Section snippets

Patient Selection

Clinical data from patients admitted to our comprehensive stroke center from November 2012 to April 2015 were retrospectively reviewed from computerized medical records that were filled prospectively during in-hospital stay. The inclusion criteria were age over 15 years old, acute ischemic stroke confirmed on brain imaging (either magnetic resonance imaging or computerized tomography), and assessment of the patient for the occurrence of pneumonia or death during hospitalization. The variables

Baseline Characteristics of the Cohort

From November 2012 to April 2015, a total of 5022 patients were admitted to our comprehensive stroke center. Among them, 2555 had an ischemic stroke, 59% were men, the mean age was 71 years old (interquartile range [IQR]: 59-81), and the median NIHSS score on admission was 8 (IQR: 4-17). In this group, the rates of in-hospital pneumonia and mortality were, respectively, 8.6% (n = 219) and 2.9% (n = 75).

Score Feasibility

Overall, all components were available for calculation of the Pn, A2DS2, and ISAN scores.

Discussion

The main results of this large single-center retrospective study are that (1) about 10% of stroke patients admitted in a comprehensive stroke unit have an SAP, (2) most of the screening tests could already be performed in our stroke units without changing our clinical practice, and (3) overall clinical utility of the different tests is the same, the simple being as efficient as the more complex.

In this study, the in-hospital SAP prevalence was 8.6%, which could be considered in the middle

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Risk Factors and Outcomes of Stroke-Associated Pneumonia in Patients with Stroke and Acute Large Artery Occlusion Treated with Endovascular Thrombectomy
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Citation Excerpt :
However, complications frequently affect clinical prognosis, as well as the duration and expense of hospitalization.5,6 Stroke-associated pneumonia (SAP) has been the most common complication following acute ischemic stroke, and the incidence varies from 2.3% to 44%.7,8 SAP increases the risk of mortality, and has been associated with poor functional outcome.9
Stroke-associated pneumonia (SAP) often increases high hospital mortality, prolongs length of hospital stay, and has considerable economic impact on healthcare costs. We aimed to explore independent predictors of SAP in acute anterior large artery occlusion patients who treated with endovascular treatment (EVT).
Consecutive patients with acute anterior large artery occlusion stroke who underwent EVT from the Nanjing Stroke Registry from January 2019 to January 2020 were identified retrospectively. Patients were divided into SAP group and Non-SAP group. In the univariate analysis, variables including demographics, clinical factors, labs, and EVT features were compared between the two groups. Then a multivariable logistic regression analysis was conducted to determine independent predictors of SAP.
One hundred and twelve patients were enrolled. Patients with SAP, compared to those without SAP, had lower modified treatment in cerebral infarction (mTICI) score 2b-3 rate (54.8% vs 85.2%; P = 0.001), higher asymptomatic intracerebral hemorrhage rate (48.4% vs 28.4%; P = 0.046), lower modified Rankin Scale (mRS) score 0–2 rate at 90days rate (9.7% vs 60.5%; P < 0.001), and higher mortality at 90days (38.7% vs 11.1%; P = 0.001). The independent predictors of SAP were dysphagia (Unadjusted Odds ratio[OR] 6.49, 95% Confidence interval[CI] 2.49–16.92; P = 0.02; Adjusted OR 3.59, 95% CI 1.19–10.83; P = 0.02), neutrophil-lymphocyte ratio (Unadjusted OR 1.19, 95% CI 1.1–1.3; P = 0.001; Adjusted OR 1.15, 95% CI 1.06–1.25; P = 0.001), and mTICI 2b-3 (Unadjusted OR 0.21, 95% CI 0.08–0.54; P = 0.001; Adjusted OR 0.3, 95% CI 0.1–0.92; P = 0.04).
Dysphagia, higher neutrophil-lymphocyte ratio, and failed recanalization were associated with SAP in acute ischemic stroke patients underwent endovascular therapy. Identification and prevention of SAP was necessary and important.
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Stroke-Associated Pneumonia Risk Score: Validity in a French Stroke Unit

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Patient Selection

Baseline Characteristics of the Cohort

Score Feasibility

Discussion

Age-based prediction of incidence of complications during inpatient stroke rehabilitation: a retrospective longitudinal cohort study

BMC Geriatr

Medical complications in patients with stroke: data validity in a stroke registry and a hospital discharge registry

Clin Epidemiol

Influence of acute complications on outcome 3 months after ischemic stroke

PLoS ONE

Post-stroke infection: a systematic review and meta-analysis

BMC Neurol

Combination of acute stroke unit and short-term stroke ward with early supported discharge decreases mortality and complications after acute ischemic stroke

J Med Assoc Thai

Pneumonia and in-hospital mortality in the context of neurogenic oropharyngeal dysphagia (NOD) in stroke and a new NOD step-wise concept

J Neurol

NIHSS and acute complications after anterior and posterior circulation strokes

Ther Clin Risk Manag

Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke

Stroke

The Pneumonia score: a simple grading scale for prediction of pneumonia after acute stroke

Am J Infect Control

Can a novel clinical risk score improve pneumonia prediction in acute stroke care? A UK multicenter cohort study

J Am Heart Assoc