Background: Hyperglycemia is always seen amongst acute intra-cerebral hemorrhage (ICH) and usually has been reported in literature and studied in relation to mortality and poor recovery. However, literature specific to stroke-associated pneumonia (SAP) on this topic is very small. Further, how to differentiate the predictive value of hyperglycemia with and without abnormal HbA1C in such patients is still a matter of debate and no universal consensus. We evaluated hyperglycemia as a marker for SAP in patients with ICH to assess its usefulness as a potential predictor. Materials and methods: Clinical characteristics for a sample of 551 patients with acute ICH were collected from the Beijing Tiantan Hospital of Capital Medical University, Beijing, China. Possible associated risk factors of SAP were reviewed. Hyperglycemia and HbA1C on admission were the main hypothetic predictor, SAP occurring within the first 7 days is the primary outcome. Results: The cohort study includes 551 hospitalized patients. The prevalence of hyperglycemia was 52.5% and SAP occurred in 147 (26.7%). The incidence of SAP was higher in the group with hyperglycemia than those without hyperglycemia (37.7% versus 14.5%, p < 0.01). Multivariate logistic regression analyses showed the SAP was significantly associated with hyperglycemia (OR, 2.48; 95% CI, 2.37 - 5.72), in the subgroup analysis we found hyperglycemia with normal HgbA1C level (<6.5) had been shown to be significantly associated with increased incidence of SAP (OR, 3.86; 95%CI, 2.98 - 6.72), however, hyperglycemia with high HgbA1C level (>6.5) (OR, 1.57; 95%CI, 0.81 - 3.23) had not been shown to be associated with SAP. Conclusions: In this hospital-based cohort of patients presenting with acute intra-hemorrhage, hyperglycemia on admission was associated significantly with SAP. The association was stronger for hyperglycemia with normal HgbA1C than for hyperglycemia with high HgbA1C. Hyperglycemia with normal HgbA1C might be a more sensitive predictor of early acute complication, such as SAP.
Post-stroke infection is the most common serious medical complication and is a significant contributor to morbidity and mortality. Of post stroke infections pneumonia frequently complicates stroke and can have a major impact on outcome. A recent meta-analysis of post-stroke infection in a large group of patients with ischemic and hemorrhagic stroke found a 10% infection rate [
This study was conducted at the Beijing Tiantan Hospital of Capital Medical University, Beijing, China, with approval of the hospital’s institutional review board. Data collected from June 2008 to December 2009 for patients with ICH were retrospectively reviewed as we before reported [
were excluded from this study. The blood glucose management including extra measurements and control depended on attending physician decision. In this study, the primary outcome measure was clinician diagnosis of SAP based on initiation of antibiotic therapy occurring within the first 7 days after admission as recorded by medical and nursing notes. SAP was diagnosed by treating physician according to the Centers for Disease Control and Prevention criteria for hospital-acquired pneumonia [
We enrolled 808 individuals into this study between June 2008 and December 2009, of which 257 patients were excluded from this analysis (counts not mutually exclusive): 149 by design (76 with death, withdrawal care, or discharge to hospice within 72 hours; 73 with recent infection); and 108 because of missing data; (47 with incomplete computed tomographic data; 61 with unavailable clinical data).Patients excluded because of missing data did not differ from included patients with respect to known predictors of ICH outcome (ICH size and location, intraventricular hemorrhage, and presenting GCS).
SAP occurred in 147 of the 551 patients (26.7%). Admission characteristics are reported in
In order to analysis the sensitivity of hyperglycemia to access SAP, we divided SAP group (147 cases) into two subgroups by the HbA1C burden (> or <6.5%). Inmultivariate logistic regression models included all variables in
SAP is a common medical complication after acute stroke. Although the treatment of acute stroke has improved, the impact of SAP on mortality may have changed little in recent years [
Patients | Patients with Diabetes Mellitus, | Patients without Diabetes Mellitus, | p-Value | Patients with Hyperglycemia on Admission | Patients without Hyperglycemia on Admission | P-Value | |
---|---|---|---|---|---|---|---|
No. patients | 551 | 113 (20.5%) | 438 (79.5%) | 289 (52.5%) | 262 (47.5%) | 0.214 | |
Age, Median (range) | 56 (23 - 88) | 61 (34 - 88) | 54 (23 - 71) | 52 (23 - 88) | 58 (27 - 74) | 0.37 | |
Male, NO. (%) | 286 (51.9%) | 101 (52.7%) | 185 (51.7%) | 0.961 | 152 (52.6%) | 134 (51.1%) | 0.952 |
*GCS, NO. (%) | <0.01 | <0.01 | |||||
<8 | 231 (41.9%) | 113 (58.5%) | 118 (33.0%) | 167 (57.8%) | 64 (24.4%) | ||
>8 | 320 (58.1%) | 80 (41.5%) | 240 (67.0%) | 122 (42.2%) | 198 (75.6) | ||
*Site of ICH, NO. (%) | |||||||
Thalamus | 86 (15.6%) | 26 (13.5%) | 60 (16.8%) | 0.683 | 42 (14.5%) | 44 (16.8%) | 0.732 |
Basal ganglia | 262 (47.5%) | 91 (47.2%) | 171 (47.8%) | 0.954 | 148 (51.2%) | 114 (43.5%) | 0.747 |
Lobar | 107 (19.4%) | 28 (14.5%) | 79 (22.1%) | 0.031 | 48 (16.6%) | 59 (22.5%) | 0.042 |
Pons | 66 (12.0%) | 36 (18.7%) | 30 (8.4%) | <0.010 | 34 (11.8%) | 32 (12.2%) | 0.864 |
Cerebellum | 30 (5.5%) | 12 (6.1%) | 18 (4.9%) | 0.385 | 17 (5.9%) | 13 (5.0%) | 0.912 |
*ICH volume, NO. (%) | <0.01 | <0.01 | |||||
Small (<30 mL) | 289 (52.5%) | 69 (35.8%) | 220 (61.5%) | 122 (42.2%) | 167 (63.7%) | ||
Large (>30 mL) | 262 (47.5%) | 124 (64.2%) | 138 (38.5%) | 167 (57.8%) | 95 (36.3%) | ||
EVD, NO. (%) | 235 (42.6%) | 104 (53.9%) | 131 (36.6%) | <0.01 | 197 (68.2%) | 38 (14.5%) | <0.01 |
IVH, NO. (%) | 85 (15.4%) | 52 (26.9%) | 33 (9.2%) | <0.01 | 63 (21.8%) | 22 (8.4%) | <0.01 |
Medical history, NO. (%) | |||||||
Abnormal liver function | 15 (2.7%) | 7 (3.6%) | 8 (2.1%) | 0.357 | 9 (3.1%) | 6 (2.3%) | 0.342 |
Renal insufficiency | 26 (4.7%) | 14 (7.3%) 11 | 12 (3.4%) | 0.003 | 15 (5.2%) | 11 (4.2%) | 0.417 |
History of pneumonia | 98 (17.8%) | 45 (23.3%) | 54 (15.1%) | <0.01 | 61 (21.1%) | 37 (14.1%) | <0.01 |
History of stroke | 103 (18.7%) | 61 (31.6%) | 42 (11.7%) | <0.01 | 57 (19.7%) | 46 (17.6%) | 0.364 |
*Initial laboratories | |||||||
WBC, median (IQR) | 6.7 (3.5 - 21.3) | 5.9 (3.5 - 19.8) | 7.6 (5.1 - 21.3) | 0.119 | 8.9 (6.3 - 21.3) | 5.2 (3.5 - 17.8) | <0.01 |
Initial blood glucose median (IQR) | 8.7 (5.1 - 19) | 10.4 (7.9 - 17.8) | 9.7 (5.1 - 19) | 0.845 | 13.2 (11.6 - 19) | 7.3 (5.1 - 11) | <0.01 |
HbA1C, median (IQR) | 5.7 (4.5 - 9.6) | 6.7 (6.1 - 9.6) | 4.5 (4.5 - 5.9) | <0.01 | 6.2 (4.8 - 9.6) | 5.9 (4.5 - 7.8) | 0.253 |
p-value of comparisons between groups with and without Diabetes Mellitus, Hyperglycemia on admission. EVD, external ventricular drain; GCS, Glasgow Coma Scale; ICH, intracerebral hemorrhage; IVH, intraventricularhemorrhage; WBC, white blood cell ; HbA1C,hemoglobin A1c; INQ, interquartile range. *Measured within the first 24 h after admission. Chi-squared test or Fisher’s exact test.
that SAP was significantly associated with hyperglycemia (OR, 2.48; 95% CI, 2.37 - 5.72) (
Variable | Patients with SAP | Patients without SAP | p-Value |
---|---|---|---|
No. patients | 147 (26.7%) | 404 (73.3) | |
Age, Median (IQR) | 65 (37 - 88) | 54 (23 - 76) | 0.019 |
Male, NO. (%) | 71 (48.3%) | 215 (53.2%) | |
*GCS, median (IQR) | 7 (3 - 15) | 9 (3 - 15) | <0.01 |
*ICH volume, median (IQR) | 35 (15 - 50) | 28 (12 - 47) | 0.113 |
*IVH, NO. (%) | 31 (21.1%) | 54 (13.4%) | <0.01 |
*EVD, NO. (%) | 63 (42.9%) | 172 (42.6%) | 0.674 |
ΔDysphagia, NO. (%) | 79 (53.7%) | 118 (29.2%) | <0.01 |
ΔMechanical ventilation, NO. (%) | 91 (61.9%) | 97 (21.5%) | <0.01 |
Diabetes Mellitus NO. (%) | 51 (34.7%) | 142 (35.1%) | 0.402 |
Chronic pulmonary disease NO. (%) | 23 (15.6%) | 54 (13.4%) | 0.267 |
History of pneumonia, NO. (%) | 12 (8.2%) | 11 (2.7%) | <0.01 |
ΔSedative NO. (%) | 107 (72.8%) | 211 (52.2%) | <0.01 |
*Hyperglycemia, NO. (%) | 109 (74.1%) | 180 (44.6%) | <0.01 |
*HbA1C, median (IQR) | 5.8 (4.6 - 9.6) | 5.4 (4.5 - 7.8) | 0.534 |
Risk factors and their association with SAP frequency within 7 days after strokeonset. Proportions are shown in brackets. *Measured within the first 24 h after admission. ΔExposed within the first 7 days after admission. Chi-squared test or Fisher’sexact test.
GlycemicStatus | Patients with SAP (n = 147) | Adjusted odds ratio | 95% Confidence interval | p-Value |
---|---|---|---|---|
Hyperglycemia AbsentNO. (%) | 38 (25.9%) | * | * | * |
Hyperglycemia Present NO. (%) | 109 (74.1%) | 2.48 | 2.37 - 5.72 | <0.001 |
Multicategory exposure variables | ||||
Hyperglycemia Absent NO. (%) | 38 (25.9%) | * | * | * |
HbA1C < 6.5 and Hyperglycemia NO. (%) | 87 (59.2%) | 3.86 | (2.98 - 6.72) | <0.001 |
HbA1C > 6.5 and Hyperglycemia NO. (%) | 22 (15.0%) | 1.57 | (0.81 - 3.23) | 0.279 |
Adjust for all variables in
hyperglycemia on admission with SAP. Being well known as hyperglycemia in relation to acute stroke is common both in patients with and in patients without a diagnosis of diabetes mellitus, and it has been suggested to worsen survival. However, recent results from several clinical studies indicate that particularly patients with acute stroke and stress hyperglycemia, but not diabetes, have increased mortality [
Current guidelines lack evidence-based recommendations for SAP prevention in stroke patients. Identifying swallowing impairments, implementing dietary modification, head elevation, and shortened use of mechanical ventilation have been emphasized [
Our results suggest that early-tight glycaemic control of hyperglycemia with normal HgbA1C, especially in high-risk patients such as those with dysphagia and mechanical ventilator support, could be an important part of an effective prevention strategy.
There are also some limitations in this study. First, this is a single center and retrospective study that could have selection bias. Secondly, the primary outcome measure of the present study is SAP occurring within the first 7 days after admission, the exact date of SAP occurred in 7 days after hospitalization isn’t documented, but SAP occurs most frequently during the first week after stroke and especially the first 3 days after stroke onset. Furthermore, the benefits of tight glycemic control (both theoretical and actual) are not taken into account in this study and more work is needed in this area. In conclusion, hyperglycemia on admission in the non-diabetic population is associated with a higher morbidity and an increased chance of developing SAP. The association is stronger for hyperglycemia with normal HgbA1C than for hyperglycemia with high HgbA1C. Hyperglycemia with normal HgbA1C might be a more sensitive predictor of early acute complication such as SAP. Our results suggest strict glucose control should be applied to SAP in patients with hyperglycemia and normal HgbA1C.
Tian-HuaRen,BiaoYuan,Tie-ChengYang,Jian-GuoLi,NiuChi,Qian-WeiRen,Hong-MeiShi,Dong-MingYu,KaiShan,Li-XiaLi,Xiao-YanDong, (2015) Impact of Admission Hyperglycemia on Stroke-Associated Pneumoniain Acute Cerebral Hemorrhage: A Retrospective Observational Study. Open Journal of Emergency Medicine,03,1-8. doi: 10.4236/ojem.2015.31001