Prevalence of and Risk Factors for Infections in Patients with Spontaneous Intracerebral Hemorrhage at the Intensive Care Unit
Intracerebral hemorrhage (ICH) is a severe neurological condition associated with high morbidity and mortality. Patients with ICH are particularly susceptible to infections, which can significantly worsen their outcomes. Infections in these patients not only increase the length of hospital stay and healthcare costs but also elevate mortality rates, worsen functional outcomes, and increase hospital readmission rates. This study aimed to determine the prevalence of infections in patients with ICH admitted to the intensive care unit (ICU), identify the associated risk factors, and evaluate the impact of infections on patient outcomes upon discharge.
The study retrospectively analyzed the discharge records of patients diagnosed with ICH in the ICU of a hospital between January 2015 and January 2019. Patients were excluded if they were hospitalized for less than 72 hours, were under 18 years of age, or had ICH caused by trauma, tumor, arteriovenous malformation, or infarction. Additionally, patients were excluded if key data, such as computed tomography results, Glasgow Coma Scale (GCS) scores, or modified Rankin Scale (mRS) scores, were not recorded. Prophylactic antibiotics were administered for no more than two days to prevent surgery-related infections or in response to an increase in white blood cell (WBC) count. The standard clinical treatments for all patients included hemostasis, reduction of intracranial pressure, anti-infection measures, and rehabilitation.
The patients were divided into two groups based on whether they developed any infection during their hospital stay. The study compared baseline demographics, risk factors, imaging findings, initial GCS scores, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, history of aspiration, incidence of invasive procedures (such as mechanical ventilation, central venous catheters, and urinary catheters), nasogastric feeding, surgical hematoma evacuation, external ventricular drainage, intubation, temperature, WBC count, and C-reactive protein (CRP) levels upon admission. Additionally, complications, including length of stay (LOS) in the ICU and mortality, as well as outcomes, were compared between the two groups. The functional outcomes of all patients were assessed at the time of discharge using the mRS, with a poor outcome defined as an mRS score of 3 to 5.
Descriptive data were presented as means ± standard deviations (SDs) or medians with upper and lower quartiles. Statistical comparisons between groups were performed using Student’s t-tests, chi-square tests, or Mann-Whitney U tests, depending on the distribution of the data. Univariate and multivariate regression analyses were conducted to identify factors associated with infections. All statistical analyses were performed using SPSS version 18.0, with a p-value of less than 0.05 considered statistically significant.
Out of 400 patient charts reviewed, 77 were excluded due to incomplete data, leaving 323 patients for the primary analysis. Among these, 183 patients (56.7%) were clinically diagnosed with at least one type of infection. Patients with infections had significantly longer hospital stays (17.40 ± 11.00 days vs. 10.70 ± 7.20 days, p < 0.05), higher admission APACHE II scores (14 ± 6 vs. 10 ± 5, p < 0.05), and poorer outcomes (discharge mRS score ≥3, 24.8% vs. 8.6%, p < 0.05). The most common infections were pneumonia (79.8%), urinary tract infections (UTIs) (22.9%), bloodstream infections (18%), and meningitis or ventriculitis (4.9%). The ICU mortality rate was 16.1%.
Gram-negative bacteria were the leading causative organisms, with the top three species being Acinetobacter baumannii, Klebsiella pneumoniae, and Staphylococcus aureus. A total of 230 bacterial strains were identified, including 54 strains of A. baumannii, 46 strains of K. pneumoniae, and 27 strains of S. aureus. The most prevalent pneumonia-causing microorganisms were pandrug-resistant K. pneumoniae, pandrug-resistant A. baumannii, and pandrug-resistant Pseudomonas aeruginosa. For UTIs, the most common microorganisms were pandrug-resistant A. baumannii, Candida albicans (sensitive to fluconazole), and pandrug-resistant Enterococcus. The primary microorganisms causing bloodstream infections were multidrug-resistant S. aureus, Staphylococcus epidermidis, and A. baumannii. Meningitis or ventriculitis was mainly caused by multidrug-resistant S. aureus and pandrug-resistant A. baumannii.
Univariate analysis identified 13 factors significantly associated with infections. In the multivariate regression model, diabetes mellitus had an odds ratio (OR) of 7.08 for developing infections (95% CI: 2.31–21.74, p = 0.001). The prophylactic use of antibiotics had an OR of 1091.08 (95% CI: 165.06–7212.27, p = 0.001). A longer hospital stay significantly increased the risk of infections (OR: 3.39, 95% CI: 1.06–10.83, p = 0.039). Patients with infections were more likely to have a lower GCS at admission (OR: 6.45, 95% CI: 1.13–36.71, p = 0.036).
Patients with infections had a higher in-hospital mortality rate than those without infections (10.5% vs. 5.6%, respectively), although the difference was not statistically significant (p = 0.220). However, the presence of infections had a significant impact on the outcome at discharge (43.2% vs. 20.3%, p < 0.001). Patients with respiratory infections alone had worse outcomes than those with urinary infections alone (46.0% vs. 36.8%, p = 0.001). The mean LOS for patients discharged alive was significantly longer for those with infections compared to those without infections (18.54 ± 11.11 days vs. 11.25 ± 7.33 days, p < 0.001). Similarly, for patients who died in the hospital, the mean LOS was significantly longer for those with infections compared to those without infections (12.41 vs. 7.50 days, p = 0.042).
This study highlights the high prevalence of infections in patients with ICH in the ICU, with approximately 56.7% of patients developing at least one type of infection. The development of infections in these patients is associated with increased ICU LOS, higher mortality rates, and poorer functional outcomes. The study identified several risk factors for infections, including diabetes mellitus, prophylactic antibiotic use, longer hospital stays, and lower GCS scores at admission. The findings underscore the importance of implementing preventive measures to reduce the rate of hospital-acquired infections in patients with ICH, which could potentially improve their outcomes.
The study also noted that infections in ICH patients may worsen outcomes through mechanisms such as inflammation, secondary neuronal injury, and cardiopulmonary deconditioning. Brain-immune interactions following stroke can lead to significant immune depression, increasing the risk of infections. Additionally, infections can exacerbate proinflammatory cascades and cause general lymphocyte activation, further contributing to poor outcomes.
Several limitations of the study should be acknowledged. First, the retrospective design may introduce bias. Second, the sample size was relatively small, and the study was conducted at a single site. Third, no long-term outcome data were available, which would have provided more insight into the effects of infections on long-term disability in ICH patients. Finally, the cause-effect relationship between infection and prolonged hospitalization remains unclear.
In conclusion, this study reveals a high frequency of infections in patients with ICH in the ICU, with significant implications for morbidity, mortality, and LOS. The findings emphasize the need for strategies to reduce infection rates in these patients, which could ultimately lead to improved outcomes and reduced healthcare costs.
doi.org/10.1097/CM9.0000000000001703
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