Aaron S. Lord

Infection After Intracerebral Hemorrhage: Risk Factors and Association With Outcomes in the Ethnic/Racial Variations of Intracerebral Hemorrhage Study

Background and Purpose— Risk factors for infections after intracerebral hemorrhage (ICH) and their association with outcomes are unknown. We hypothesized there are predictors of poststroke infection and infections drive worse outcomes. Methods— We determined prevalence of infections in a multicenter, triethnic study of ICH. We performed univariate and multivariate analyses to determine the association of infection with admission characteristics and hospital complications. We performed logistic regression on association of infection with outcomes after controlling for known determinants of prognosis after ICH (volume, age, infratentorial location, intraventricular hemorrhage, and Glasgow Coma Scale). Results— Among 800 patients, infections occurred in 245 (31%). Admission characteristics associated with infection in multivariable models were ICH volume (odds ratio [OR], 1.02/mL; 95% confidence interval [CI], 1.01–1.03), lower Glasgow Coma Scale (OR, 0.91 per point; 95% CI, 0.87–0.95), deep location (reference lobar: OR, 1.90; 95% CI, 1.28–2.88), and black race (reference white: OR, 1.53; 95% CI, 1.01–2.32). In a logistic regression of admission and hospital factors, infections were associated with intubation (OR, 3.1; 95% CI, 2.1–4.5), dysphagia (with percutaneous endoscopic gastrostomy: OR, 3.19; 95% CI, 2.03–5.05 and without percutaneous endoscopic gastrostomy: OR, 2.11; 95% CI, 1.04–4.23), pulmonary edema (OR, 3.71; 95% CI, 1.29–12.33), and deep vein thrombosis (OR, 5.6; 95% CI, 1.86–21.02), but not ICH volume or Glasgow Coma Scale. Infected patients had higher discharge mortality (16% versus 8%; P=0.001) and worse 3-month outcomes (modified Rankin Scale ≥3; 80% versus 51%; P<0.001). Infection was an independent predictor of poor 3-month outcome (OR, 2.6; 95% CI, 1.8–3.9). Conclusions— There are identifiable risk factors for infection after ICH, and infections predict poor outcomes.Background and Purpose Risk factors for infections after intracerebral hemorrhage (ICH) and their association with outcomes are unknown. We hypothesized there are predictors of post-stroke infection and infections drive worse outcomes.

Time Course and Predictors of Neurological Deterioration After Intracerebral Hemorrhage

Background and Purpose— Neurological deterioration (ND) is a devastating complication after intracerebral hemorrhage but little is known about time course and predictors. Methods— We performed a retrospective cohort study of placebo patients in intracerebral hemorrhage trials. We performed computed tomographic scans within 3 hours of symptoms and at 24 and 72 hours; and clinical evaluations at baseline, 1-hour, and days 1, 2, 3, and 15. Timing of ND was predefined as follows: hyperacute (within 1 hour), acute (1–24 hours), subacute (1–3 days), and delayed (3–15 days). Results— We enrolled 376 patients and 176 (47%) had ND within 15 days. In multivariate analyses of ND by category, hyperacute ND was associated with hematoma expansion (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7–7.6) and baseline intracerebral hemorrhage volume (OR, 1.04 per mL; 95% CI 1.02–1.06); acute ND with hematoma expansion (OR, 7.59; 95% CI, 3.91–14.74), baseline intracerebral hemorrhage volume (OR, 1.02 per mL; 95% CI, 1.01–1.04), admission Glasgow Coma Scale (OR, 0.77 per point; 95% CI, 0.65–0.91), and interventricular hemorrhage (OR, 2.14; 95% CI, 1.05–4.35); subacute ND with 72-hour edema (OR, 1.03 per mL; 95% CI, 1.02–1.05) and fever (OR, 2.49; 95% CI, 1.01–6.14); and delayed ND with age (OR, 1.11 per year; 95% CI, 1.04–1.18), troponin (OR, 4.30 per point; 95% CI, 1.71–10.77), and infections (OR, 3.69; 95% CI, 1.11–12.23). Patients with ND had worse 90-day modified Rankin scores (5 versus 3; P<0.001). Conclusions— ND occurs frequently and predicts poor outcomes. Our results implicate hematoma expansion and interventricular hemorrhage in early ND, and cerebral edema, fever, and medical complications in later ND.

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

Introduction. Comparison of rates of ventriculostomy-related infections (VRIs) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis. Materials and methods. We conducted a PubMed search for definitions of VRI using the search strings “ventriculostomy-related infection” and “ventriculostomy-associated infection.” We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition. Results. We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22 to 94% (median 61% with interquartile range (IQR) 56–74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56 to 89% (median: 72%, IQR: 71–78%). Conclusions. The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed.

Public education and misinformation on brain death in mainstream media.

We sought to evaluate the caliber of education mainstream media provides the public about brain death.

Majority of 30-Day Readmissions After Intracerebral Hemorrhage Are Related to Infections

Background and Purpose— Infections are common after intracerebral hemorrhage, but little is known about the risk of serious infection requiring readmission after hospital discharge. Methods— To determine if infections are prevalent in patients readmitted within 30 days of discharge, we performed a retrospective cohort study of patients discharged from nonfederal acute care hospitals in California with a primary diagnosis of intracerebral hemorrhage between 2006 and 2010. We excluded patients who died during the index admission, were discharged against medical advice, or were not California residents. Our main outcome was 30-day unplanned readmission with primary infection–related International Classification of Diseases, Ninth Revision, Clinical Modification code. Results— There were 24 540 index intracerebral hemorrhage visits from 2006 to 2010. Unplanned readmissions occurred in 14.5% (n=3550) of index patients. Of 3550 readmissions, 777 (22%) had an infection-related primary diagnosis code. When evaluating primary and all secondary diagnosis codes, infection was associated with 1826 (51%) of readmissions. Other common diagnoses associated with readmission included stroke-related codes (n=840, 23.7%) and aspiration pneumonitis (n=154, 4.3%). The most common infection-related primary diagnosis codes were septicemia (n=420, 11.8%), pneumonia (n=124, 3.5%), urinary tract infection (n=141, 4.0%), and gastrointestinal infection (n=42, 1.2%). Patients with a primary infection–related International Classification of Diseases, Ninth Revision, Clinical Modification code on readmission had higher in-hospital mortality compared with other types of readmission (15.6% versus 8.0%, P<0.001). After controlling for other predictors of mortality, primary infection–related readmissions remained associated with in-hospital mortality (relative risk, 1.7; 95% confidence interval, 1.3–2.2). Conclusions— Infections are associated with a majority of 30-day readmissions after intracerebral hemorrhage and increased mortality. Efforts should be made to reduce infection-related complications after hospital discharge.

Discharge educational strategies for reduction of vascular events (DESERVE): design and methods

Rationale Stroke and vascular risk factors disproportionately affect minority populations, with Blacks and Hispanics experiencing a 2.5- and 2.0-fold greater risk compared with whites, respectively. Patients with transient ischemic attacks and mild, nondisabling strokes tend to have short hospital stays, rapid discharges, and inaccurate perceptions of vascular risk. Aim The primary aim of the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial is to evaluate the efficacy of a novel community health worker-based multilevel discharge intervention vs. standard discharge care on vascular risk reduction among racially/ethnically diverse transient ischemic attack/mild stroke patients at one-year postdischarge. We hypothesize that those randomized to the discharge intervention will have reduced modifiable vascular risk factors as determined by systolic blood pressure compared with those receiving usual care. Sample size estimates Given 300 subjects per group and alpha of 0.05, the power to detect a 6 mmHg reduction in systolic blood pressure is 89%. Design DESERVE trial is a prospective, randomized, multicenter clinical trial of a novel discharge behavioral intervention. Patients with transient ischemic attack/mild stroke are randomized during hospitalization or emergency room visit to intervention or usual care. Intervention begins prior to discharge and continues postdischarge. Study outcomes The primary outcome is difference in systolic blood pressure reduction between groups at 12 months. Secondary outcomes include between-group differences in change in glycated hemoglobin, smoking rates, medication adherence, and recurrent stroke/transient ischemic attack at 12 months. Discussion DESERVE will evaluate whether a novel discharge education strategy leads to improved risk factor control in a racially diverse population.

Prognosticating Functional Outcome After Intracerebral Hemorrhage: The ICHOP Score

BACKGROUND The morbidity, mortality, and monetary cost associated with intracerebral hemorrhage (ICH) is devastatingly high. Several scoring systems have been proposed to prognosticate outcomes after ICH, although the original ICH Score is still the most widely used. However, recent research suggests that systemic physiologic factors, such as those included in the Acute Physiology and Chronic Health Evaluation II score, may also influence outcome. In addition, no scoring systems to date have included premorbid functional status. Therefore, we propose a scoring system that incorporates these factors to prognosticate 3-month and 12-month functional outcomes. METHODS We used the Random Forest machine-learning technique to identify factors from a dataset of more than 200 data points per patient that were most strongly affiliated with functional outcome. We then used linear regression to create an initial model based on these factors and modified weightings to improve accuracy. Our scoring system was compared with the ICH Score for prognosticating functional outcomes. RESULTS Two separate scoring systems (Intracerebral Hemorrhage Outcomes Project 3 [ICHOP3] and ICHOP12) were developed for 3-month and 12-month functional outcomes using Glasgow Coma Scale, National Institutes of Health Stroke Scale, Acute Physiology and Chronic Health Evaluation II, premorbid modified Rankin Scale (mRS), and hematoma volume (3-month only). Patient outcomes were dichotomized into good (mRS score, 0-3) and poor (mRS score, 4-6) categories based on functional status. Areas under the curve in the derivation cohort for predicting mRS score were 0.89 (3-month) and 0.87 (12-month); both were significantly more discriminatory than the original ICH Score. CONCLUSIONS The ICHOP scores may provide more comprehensive evaluation of a patients long-term functional prognosis by taking into account systemic physiologic factors as well as premorbid functional status.

Prolonged prophylactic antibiotics with neurosurgical drains and devices: Are we using them? Do we need them?

Surgical site infections (SSIs) after neurosurgical procedures can have devastating consequences. As a result, during the periand postoperative periods, practitioners are extremely cautious about trying to prevent SSI.1 One method that is commonly employed to avert SSI is administration of prolonged prophylactic systemic antibiotics (PPSA) to patients with neurosurgical drains and devices.2,3 There are no data to support routine use of antibiotics until all drains and devices are removed after neurosurgical procedures.4 May et al3 compared frequency of infection in patients with intracranial monitors in a single institution who received no antibiotic prophylaxis, narrow-spectrum antibiotic prophylaxis, and broadspectrum antibiotic prophylaxis and found no significant difference. Review of the literature on risk of infection in patients with lumbar drains showed that there is a 4%-7% risk of infection in this population, even in the absence of PPSA.5,6 Data from a prospective study of 448 patients showed no significant relationship between presence of a subdural or subgaleal drain and development of infection.1 A literature review from 1980-2004 showed that incidence of infection after spinal surgery was generally ≤3%, but could increase as high as 12% with use of instrumentation, and even higher when drains were left in place. Despite this, the British Society for Antimicrobial ChemotherapyWorking Party for Neurosurgical Infections concluded that there was insufficient evidence to support use of PPSA for coverage of lines, drains, or catheters after spinal procedures.7 Nonetheless, practitioners often cite the desire “to be safe” as a reason for antibiotic administration.8 PPSA use is not really safe, because it is associated with: increased risk of Clostridium difficile infection; adverse drug reactions, including anaphylaxis or systemic toxicity; and growth of resistant pathogens.2,3 As a result, clinical practice guidelines on antibiotic administration to patients undergoing surgery published in 2013 recommended that neurosurgery patients be given antibiotics for a maximum of 24 hours after surgery and discouraged PPSA use, even when drains or devices are left in place.4 To evaluate current practice patterns related to PPSA administration to neurosurgery patients with drains and devices and practitioner perception about the need for PPSA in this population, we distributed a survey to the 1,000 members of the Neurocritical Care Society from April-July 2015. The survey was completed by 52 respondents (5% response rate). Respondents reported routine institutional use of PPSA with every drain and device: Jackson-Pratt spinal drains with instrumentation (52%), subdural drains (48%), lumbar drains (46%), intraparenchymalmonitors (42%), Jackson-Pratt spinal drainswithout instrumentation (33%), and subgaleal drains (29%). Respondents had varying personal opinions on the need for PPSA with both intracranial and spinal drains or devices (Fig 1). The highest percentage of respondents who agreed or strongly agreed with the need for PPSA for a given drain or device was for patients with Jackson-Pratt spinal drains with instrumentation (35%), whereas the lowest was for patients with subgaleal drains (19%). Establishment of consensus and development of practice guidelines has led to a significant improvement in antibiotic use, incidence of nosocomial infections, and cost of care,9 but it is clear that guidelines are not consistently followed. Our findings show that PPSA are frequently administered to patients with drains and devices after neurosurgical procedures. Furthermore, only a small percentage (29%) of survey respondents disagreed with the need for PPSA for all neurosurgical drains or devices. This reflects either a lack of awareness or indifference to the guidelines and data that indicate PPSA are not necessary for neurosurgery patients with drains or devices.10 The Joint Commission tracks use of prophylactic antibiotics and rates of discontinuation after 24 hours for a number of surgical procedures, but they do not presently do so for neurosurgical procedures.11 It is reasonable to expect they will do so in the future. A combined effort by pharmacists and physicians to establish consensus and develop local practice guidelines can have a tremendous influence on prescribing practices because local guidelines are more likely to be accepted and adhered to than national guidelines.9,10 In the absence of such, physicians may allow anecdotal experience to guide their use of PPSA.12 Pharmacists can employ persuasive techniques (eg, advise practitioners on how to prescribe antibiotics) or restrictive techniques (eg, limit how antibiotics can be prescribed) to scale down the frequency of inappropriate antimicrobial administration. A Cochrane Review found that both interventions were equally effective.13 Practice surveys such as this are associatedwith a number of limitations. Although our cohort was small, we believe that the variety of responses we received effectively demonstrates that institutions are still administering PPSA to neurosurgery patients despite recommendations to the contrary, and that practitioners need more education and local guidelines on use of antibiotic prophylaxis in this population.

Systemic inflammatory response syndrome, infection, and outcome in intracerebral hemorrhage

Objective: Systemic inflammatory response syndrome (SIRS) may be related to poor outcomes after intracerebral hemorrhage (ICH). Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage study is an observational study of ICH in whites, blacks, and Hispanics throughout the United Sates. SIRS was defined by standard criteria as 2 or more of the following on admission: (1) body temperature <36°C or >38°C, (2) heart rate >90 beats per minute, (3) respiratory rate >20 breaths per minute, or (4) white blood cell count <4,000/mm3 or >12,000/mm3. The relationship among SIRS, infection, and poor outcome (modified Rankin Scale [mRS] 3–6) at discharge and 3 months was assessed. Results: Of 2,441 patients included, 343 (14%) met SIRS criteria at admission. Patients with SIRS were younger (58.2 vs 62.7 years; p < 0.0001) and more likely to have intraventricular hemorrhage (IVH; 53.6% vs 36.7%; p < 0.0001), higher admission hematoma volume (25.4 vs 17.5 mL; p < 0.0001), and lower admission Glasgow Coma Scale (GCS; 10.7 vs 13.1; p < 0.0001). SIRS on admission was significantly related to infections during hospitalization (adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.04–1.78). In unadjusted analyses, SIRS was associated with poor outcomes at discharge (OR 1.96, 95% CI 1.42–2.70) and 3 months (OR 1.75, 95% CI 1.35–2.33) after ICH. In analyses adjusted for infection, age, IVH, hematoma location, admission GCS, and premorbid mRS, SIRS was no longer associated with poor outcomes. Conclusions: SIRS on admission is associated with ICH score on admission and infection, but it was not an independent predictor of poor functional outcomes after ICH.

Variations in Strategies to Prevent Ventriculostomy-Related Infections: A Practice Survey

Background and Purpose: The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. Methods: We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. Results: The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents’ institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. Conclusion: Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.