Early Predictors for Infectious Complications in Patients With Spontaneous Intracerebral Hemorrhage and Their Impact on Outcome

Abstract

Background: Infectious complications (IC) commonly occur in patients with intracerebral hemorrhage (ICH) and are associated with increased length of hospitalization (LOS) and poor long-term outcome. Little is known about early ICH-related predictors for the development of IC to allow appropriate allocation of resources and timely initiation of preventive measures. Methods: We prospectively enrolled 229 consecutive patients with non-traumatic ICH admitted to the neurocritical care unit (NICU) of a tertiary care hospital. Patients were screened daily for IC. Multivariable regression models using generalized linear models were used to identify associated factors with the occurrence of IC and to study their impact on functional outcome, which was assessed using the modified Rankin Scale Score (mRS) after 3 months. Unfavorable outcome was defined as mRS ≥3. Results: The most common IC were pneumonia (n = 64, 28%) and urinary tract infection (n = 54, 24%), followed by sepsis (n = 9, 4%) and ventriculitis (n = 4, 2%). Patients with a higher admission ICH Score (>2) had higher odds to develop any IC during NICU stay (OR = 1.7, 95% CI 1.2-2.3, p = 0.02). Moreover, early-onset pneumonia (≤48 h after admission) was predictive of sepsis occurring at a later time-point (median at day 11 [IQR = 6-34 days], adjOR = 22.5, 95% CI 4.88-103.6, p < 0.001). Having at least one IC and pneumonia itself were independently associated with unfavorable 3-months outcome (adjOR = 3.0, 95% CI 1.41-6.54, p = 0.005; adjOR = 4.2, 95% CI 1.33-13.19, p = 0.015, respectively). All patients with sepsis died or had poor functional outcome. Conclusions: Infectious complications are common in ICH patients and independently associated with unfavorable outcome. An ICH Score >2 on admission and early pneumonia may help to early identify patients at high risk of IC to allocate resources and start careful surveillance.

Keywords: critical care; infections; infectious complications; intracerebral hemorrhage; neurology; risk factors.

Figure 1

Flow chart showing the selection of eligible patients.

Figure 2

Graphs display absolute numbers of cases with infectious complications (y-axis) based on days after admission (x-axis) for (A) pneumonia, (B) ventriculitis, (C) sepsis, and (D) UTI (urinary tract infection). Pneumonia and UTI were mainly diagnosed in the first week after ictus (day 5 [IQR 2–9 days]; day 11 [IQR 3–25 days], respectively), whereas sepsis (C) and ventriculitis (B) occurred more frequently in the second week (day 11 [IQR 6–34 days]; day 11 [IQR 9–25 days], respectively).

Figure 3

Represents relative prevalence of diagnosed infections per day/per patient to account for patients still admitted to the ICU. The absolute number of infections per day was divided by the number of patients per day. N patients, number of patients.

Figure 4

(A) Kaplan-Meier-Curve describing the probability of any infectious complication in patients with ICH Score ≤2 and >2. Patients were censored at the time of: withdrawal of care, NICU discharge, or death latest on day 30. Distribution of individual infections in patients with infections stratified by (B) an admission ICH Score ≤2 and (C) ICH Score >2.

Figure 5

Length of NICU stay: Patients without any infection had a median LOS of 5 days [IQR 2–8 days], patients suffering from one infection 14 days [IQR 5–21 days], while patients suffering from two or more infections stayed 29 days [IQR 16–44 days] at NICU. All patients staying longer than 30 days were censored at day 30.